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What age bracket do you fall in? *
Which of the following best describes your menstruation cycle? *

1. Hot flushes & night sweats (Intense spreading of heat, usually across the chest, neck or face excessive sweating) *

2. Experiencing sleep issues (Difficulty falling or remaining asleep tossing, turning, or fitful sleep) *

3. Experiencing joint pains (Muscular discomfort, feeling of unusual stiffness & soreness) *

4. Heart discomfort (Unusual awareness of heartbeat, heart skipping, heart racing, tightness) *

5. Skin & hair changes (Dry, itchy skin, thinning or coarsening of hair, new facial hair, appearance of dark spots) *

6. Weight Gain (weight has increased, especially around abdomen & thighs, feeling bloated) *

7. Feeling of anxiety (inner restlessness, feeling panicky, overly worried or tense) *

8. Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings) *

9. Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness) *

10. Sexual problems (change in sexual desire, sexual activity and satisfaction) *

11. Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence) *

12. Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse) *

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