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DUTCH Survey

Please answer these questions to the best of your ability to help determine if hormone testing would be beneficial for you. After you submit your responses, we will share more information on whether or not hormone testing is right for you, and which test we recommend.

*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

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

Question 4 of 12

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

Question 5 of 12

What are the main hormone related challenges you are currently experiencing?

(Select all that apply)
A

Hair Issues (loss of scalp hair, slow growth, increased body/facial hair)

B

Skin Concerns (dry skin, acne, etc)

C

Low libido or changes in sexual drive

D

Mood swings, irritability, or anxiety

E

Irregular menstrual cycles

F

Painful or heavy periods

G

Uterine Fibroids

H

Hot flashes or night sweats

I

Vaginal Dryness

J

Persistent fatigue or low-energy

K

Difficulty losing weight or unexplained weight gain

L

Sleep issues (difficulty falling asleep, staying asleep, or waking up unrefreshed)

M

Brain fog or difficulty focusing

N

Digestive issues (bloating, constipation, etc.)

O

Frequent headaches or migraines

P

None of the above apply

Question 6 of 12

Are you struggling with infertility?

A

Yes

B

No

Question 7 of 12

Have you been diagnosed with insomnia?

A

yes

B

no

Question 8 of 12

How would identify your stress level day to day? (Rated from 0-10)

(Select all that apply)
A

Low amount of stress (0-3)

B

Medium amount of stress (4-6)

C

High amount of stress (7-10)

Question 9 of 12

When is your fatigue the worst? Please also rate it on a scale of 1-10.

(Select all that apply)
A

My fatigue is worst in the morning

B

My fatigue is worst in the afternoon

C

My fatigue is worst in the evening

D

It's a 1-3

E

It's a 4-6

F

It's a 7-9

G

It's a 10

Question 10 of 12

How do these symptoms affect your daily life?

(Select all that apply)
A

I feel constantly exhausted

B

I struggle to keep up with my kids/family

C

My relationships are impacted due to mood swings or low libido

D

I don’t feel like myself anymore

E

I’ve lost confidence in my body and health

F

My work or productivity is suffering due to fatigue or brain fog

Question 11 of 12

Please select which one applies to you:

(Select all that apply)
A

I am NOT in menopause

B

I am in perimenopause

C

I am in menopause

D

I am post menopausal

E

I'm not sure, but I think I may be in perimenopause

Question 12 of 12

What are your biggest health goals right now?

(Select all that apply)
A

Restoring energy and vitality

B

Achieving sustainable weight loss

C

Regulating my menstrual cycle

D

Optimizing fertility

E

Stabilizing my mood and emotions

F

Improving libido and sexual health

G

Sleeping better and waking up refreshed

H

Feeling in control of my body and health

I

Healing naturally without dependence on medications

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