Women’s MyT Survey

 

    Your Name:

    Your Email:

    City:

    State:

    ZIP:

    Phone:

    1. I have noticed a dramatic decrease in my energy levels.
    YesNo

    2. For the most part, I have poor sleep quality.
    YesNo

    3. I tend to experience night sweats and/or hot flashes.
    YesNo

    4. I often find it difficult to lose weight.
    YesNo

    5. I have noticed a loss of muscle mass in my body.
    YesNo

    6. I tend to carry excess weight in my mid-section.
    YesNo

    7. I have a decreased libido or loss of sexual desire.
    YesNo

    8. I experience frequent feelings of anger/anxiety/depression.
    YesNo

    9. I have had a hysterectomy. If yes, please specify the year:
    YesNo

    10. I have had a tubal ligation. If yes, please specify the year:
    YesNo

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