First Name *Family Name *Email Address *Phone *Year of Birth *Date of the Last Period *SYMPTOMS EVALUTION TABLE(Symptoms Intensity: 0, 1,2,3 (0: No Symptoms, 1: Mild, 2: Medium, 3: Strong)PHYSICAL SYMPTOMSHot Flushes *Select0123Night Sweats *Select0123Slow Digestion *Select0123Low Energy / Fatigue *Select0123Hair Loss / Weak Nails *Select0123Intestinal Problems *Select0123Weight Gain *Select0123Feeling Bloated *Select0123Joints Pain *Select0123Headache / Migraine *Select0123Dry Skin / Itching Skin *Select0123Sore / Swollen Breast *Select0123Irregular Periods *Select0123OR Heavy PeriodsAllergies *Select0123Heart Palpitations *Select0123Tingling Extremities *Select0123Body Temperature Swings *Select0123Hot/ColdInsomnia / Sleeping Disorder *Select0123Fat in the Belly Area & Arms *Select0123MENTAL / EMOTIONALAnxiety *Select0123Mood Swings *Select0123Stressed *Select0123Loss of Confidence *Select0123Bursts of Anger *Select0123Feeling Sad *Select0123Panic Attacks *Select0123Feeling Overwhelmed *Select0123Brain Fog / Bad Memory *Select0123Crying/Weeping with No Reason *Select0123GENITOURINARY SYMPTOMSVaginal Dryness *Select0123Vaginal Discharge *Select0123Loss of Libido *Select0123Bladder Issues / Incontinence *Select0123Painful Sex *Select0123GENERAL HEALTH (Check the related box, if Yes)Osteoporosis /OsteopeniaHigh CholesterolEndometriosisPolycystic OvariesCardiovascular issuesMyoma / FibroidsBreast / Uterine CancerArthritisTendinitisBack problemsCervical ProblemsDiabetesHyperthyroidismHypothyroidismPremature MenopausePerimenopauseMenopausePost MenopauseOtherARE YOU TAKING ANY MEDICATIONS OR SUPPLEMENTS?E.g. Hormone replacement therapy (HRT), Anti-depresant, vitamins, magnesium...Please write the name of the products you takePlease Note: The normal age range of menopause is between 40 to 58 years old. However, about 1% of women have a premature menopause. Some of the above symptoms can start up to 6-8 years prior the last period and continue for 8-10 years after. The symptoms and their intensity can vary with time. In case of hysterectomy, the symptoms can appear all at once.Please Note: These data will not be communicated to anybody and will only be used to assess the feasibility of practicing Hormone Yoga and to track the improvement of the symptoms SUBMIT