Confidential screening questionnaire to identify symptom patterns and the best next step.
Performance Powered By Wellness™
Feeling “off” isn’t a personality flaw — it’s often a physiology + lifestyle signal. This quick screening helps identify symptom patterns commonly seen in perimenopause, menopause, PMS/cycle shifts, thyroid-stress patterns, and metabolic strain.
Screening → labs when appropriate → individualized plan → follow-through → perform at your best.
After you submit: you’ll be prompted to Book Now to review investment and schedule your visit.
Required checkboxes
Section 1 — Contact + eligibility
Section 2 — My Hormone Season
Section 3 — Core Symptom Signal
In the last 30 days, how often?
0–7 (Low): Realign —You did not screen positive today. Tighten foundations and prevent escalation. If symptoms persist, we can still evaluate other high-impact drivers (sleep, stress physiology, metabolic health, thyroid patterns, nutrient status, medications).
Goal: Reset the fundamentals and prevent escalation.
8–15 (Moderate): You screened positive for hormone-related symptom patterns. Stabilize patterns with clinician-guided next steps. This does not diagnose a condition. The next step is a clinician-guided review and labs when clinically appropriate, followed by a personalized plan.
Goal: Restore stability with targeted supports and structured follow-through.
16-30: (High): Rebalance — You screened positive for hormone-related symptom patterns. Comprehensive, phased strategy with structured follow-through. This does not diagnose a condition. The next step is a clinician-guided review and labs when clinically appropriate, followed by a personalized plan.
Goal: Rebalance the whole system over time—sequenced, not rushed.
Note: This screening highlights symptom patterns and does not diagnose a condition. Treatment decisions require clinician review and labs when indicated.
Section 4 — Goal focus
Section 5 — Quick safety/triage
👉🏼Book Now to review investment and schedule your visit.
Scroll to Submit. A team member will contact you shortly.
Instructions: Check all symptoms that apply to you. When finished, look for the column with the most boxes checked—that area is most likely connected to the reason you’ve been feeling off.
Important Information About This Form: Submitting this form does not create a medical provider/doctor–patient relationship, provide medical advice, diagnosis, treatment or initiate a health record with our clinic.
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