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Inspired Vitality Assessment

Step 1 of 43

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First Name(Required)

Last name(Required)

Country

Email

Consent

Do You Agree to our Terms & Conditions / Privacy Policy?

How old are you?(Required)

Less than 20	21-30	31-40	41-50	51-60	60+

Have You Had Any Children?

0

1-2

3+

Do You Have A Menstrual Cycle?

Yes

No

Are You Taking, or have You ever taken, any form of birth control?

Yes, Currently

Yes, In the past 5 years

No, or ceased longer than 5 years ago

Are You Menopausal, or do suspect you are Menopausal?

Yes

No

Are You Perimenopausal, or do you suspect you are Peri Menopausal?

Yes

No

Are You Taking Hormone Replacement Therapy?

Yes

No

Are You Taking Pain Medications?

Yes

No

Have you been diagnosed with, or suspect you may have Endometriosis?

Yes

No

Have you been diagnosed with, or suspect you may have PCOS (Polycystic Ovary Syndrome)?

Yes

No

Have you been diagnosed with Adenomyosis?

Yes

No

Do you have Fibroids?

Yes

No

Do you have Ovarian Cysts?

Yes

No

Do you suffer from Breast Cysts?

Yes

No

Have you been diagnosed with, or do you suspect you might have, Premenstrual Dysphoric Disorder (PMDD)?

Yes

No

Have you been diagnosed with a thyroid condition such as Hypothyroidism or Hyperthyroidism?

Yes

No

Do you have sugar cravings?

Yes

No

Have you been diagnosed with or do you suspect you have Insulin Resistance?

Yes

No

Do you have signs of thyroid imbalance?

Yes

No

Have you been diagnosed with or do you suspect you have Adrenal Dysfunction?

Yes

No

Do you have a good libido / sex drive?

Yes

No

Do you need to lose weight or do you struggle to lose weight?

Yes

No

Do you experience any of the following premenstrual syndrome (PMS) signs and symptoms?

Yes

No

mood swings
irritability, depression
fluid retention
breast tenderness or soreness
fluid retention or bloating
headaches or migraine
food cravings
skin breakouts / acne

Do you have heavy, clotty or light menstrual bleeding?

Yes

No

Do you have irregular periods?

Yes

No

Do you have painful periods?

Yes

No

Do you have periods which last longer than 7 days?

Yes

No

Do you experience anxiety or depression?

Yes

No

Do you experience a lot of stress, or have done so in the past?

Yes

No

Do you have trouble sleeping?

Yes

No

Do you work as a shift worker?

Yes

No

Do you suffer from Brain Fog, Concentration or Memory Issues?

Yes

No

Do you suspect you may be in PeriMenopause?

Yes

No

Are you in Menopause or do you feel you have Menopausal Symptoms?

Yes

No

Do you experience Hot Flushes?

Yes

No

Do you experience frequent urination, urinary tract infections or ‘leakage’?

Yes

No

Do you experience Vaginal Dryness?

Yes

No

Have you started to experience sinus issues or allergies?

Yes

No

Do you have dry skin?

Yes

No

Do you have aches and pains?

Yes

No

Is your hair thinning?

Yes

No

Almost done....

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