PeriMeno Quickie with Simone Questionnaire

Is this appointment appropriate for you?

I am at least 42 years old(Required)

Yes

No

If you are age 42 or younger, there may be other reasons for your hormonal symptoms such as thyroid or prolonged stress, rather than perimenopause. Please check with your doctor and rebook a Comprehensive Care Consultation with Simone. Contact info@myvagina.com if you need help with bookings.

I have experienced breast cancer or other female reproductive cancer in the past(Required)

Yes

No

This appointment is for uncomplicated perimenopause. If you have a history of female cancers, a partial hysterectomy or have a hormonal IUD, please book a Comprehensive Care Consultation with Simone. Contact info@myvagina.com if you need help with bookings.

Email(Required)

Enter Email Confirm Email

Name(Required)

First Last

Date of Birth(Required)

Age(Required)

Phone(Required)

Address(Required)

Country

Supplements, herbs and medicines

Please list all supplements, herbs and medicines you are currently taking (if none, please say)(Required)

One last thing! Please explain what your symptoms are and what's going on for you(Required)

PeriMeno Quickie with Simone Questionnaire

Is this appointment appropriate for you?

Menstrual patterns

Supplements, herbs and medicines

Underlying conditions

Anxiety and mood

Sleep

Vaginal and urinary tract symptoms