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1. Rate your current health on a scale of 1 to 5 (with 5 being the best/highest rating) *

2. Do you find that your body is gaining weight differently through peri-menopause and menopause?

Yes

No

None of the above

3. How many times a week do you eat-out/have take-out or go to a drive through?

1-2 times

3-4 times

5-7 times

Never, we always eat in

4. Are you unhappy looking in the mirror?

Yes

No

5. Is body image & self-esteem a concern?

6. Do you find that old solutions for weight loss don't work anymore?

Yes

No

7. Have you considered that hormone imbalance could be a big cause of weight gain?

Agree

Disagree

8. Are you experiencing more weight gain in your tummy area?

Yes

No

9. Are you a stress eater?

Yes

No

None of the above

10. With menopause, do you find your clothes fitting differently?

Yes

No

11. How does your body image affect you personally and emotionally?

It doesn't affect me

It affects me somewhat - some days I don't feel the best about myself

It affects me a great deal - most days or all days I don't feel the best about myself

12. Do you avoid social engagements out of embarrassment?

Yes

No

13. Are you struggling with sugar cravings?

Yes

No

14. Are you worried about the health implications of weight gain?

Yes

No

16. Are you struggling with night sweats?

Yes

No

17. Do you wake up repeatedly throughout the night?

Yes

No

19. Does lack of sleep make you moody and irritable?

Yes

No

22. How many times per week do you consume alcohol?

Daily - over two drinks per day

2-3 times per week - over two drinks per day

4-5 times per week - over two drinks per day

6-7 times per week - over two drinks per day

Never, I don't consumer alcohol