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

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

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

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