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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!

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Question 1 of 12

Email address:

Question 2 of 12

First and Last Name:

Question 3 of 12

Do you live in the United States or Canada?

A

Yes

B

No

Question 4 of 12

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

Question 5 of 12

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

Question 6 of 12

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

Question 7 of 12

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

Question 8 of 12

Are you struggling with infertility?

A

Yes

B

No

Question 9 of 12

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 10 of 12

Have you had trauma in your past? 

A

yes

B

no

C

maybe

Question 11 of 12

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

Question 12 of 12

Would you like to receive more information on the next Female Hormone Solution Program?

A

yes

B

no

Confirm and Submit