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DUTCH Survey

Please answer these questions to the best of your ability to help us determine which DUTCH test is right for you! After you submit your responses, we will review them and send you more information on getting started.

*Please note in order for us to send you more information you must check the box "subscribe to our email list" on the very last page before you hit submit!

Click the button below to start.

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Question 1 of 11

Email address:

Question 2 of 11

First and Last Name:

Question 3 of 11

What is the main reason you are wanting to have your hormones tested?

Question 4 of 11

What hormonal imbalances or symptoms of hormone imbalance are you experiencing?

Question 5 of 11

Are you on birth control? If yes, what kind?

Question 6 of 11

Are you on hormone replacement therapy? If yes, what kind?

Question 7 of 11

Are you struggling with infertility?

A

Yes

B

No

Question 8 of 11

Please mark all that you struggle with:

(Select all that apply)
A

irregular cycles

B

menopause

C

hot flashes

D

infertility

E

weight gain

F

fatigue

G

low libido

H

mood swings

I

depression

J

insomnia/sleep issues

Question 9 of 11

Have you been diagnosed with insomnia?

A

yes

B

no

Question 10 of 11

On a scale of 1-10 rate your stress level (1 being no stress, 10 being highly stressful):

Question 11 of 11

Are you interested in receiving emails with more information on the next 12 week program & being notified when registration opens?

A

Yes!

B

No

Confirm and Submit