BalAge Rx℠Lifestyle
Questionnaire


Ready to begin, then let's start with your hormone BalAge Rx Lifestyle Quiz. Once completed, your BalAge Rx℠ consultant will give you information about where you are in your Balance Journey and how to proceed.

Questions about your sleeping patterns.
1. I have trouble sleeping. *
2. I feel fatigued even though I get more than 6 hours of sleep a night. *
3. I wake up with hot flashes or night sweats. *
4. I have insomnia with excessive nervous tension and anxiety. *
Questions about your body.
5. My hair is losing texture or I am gaining hair in new places. (ex: chin, areola) *
6. I am becoming sick more often, especially common colds. *
7. I have experienced increased tenderness in my breasts. *
8. I am becoming sick more often, especially common colds.
Questions about exercise & weight
9. I exercise regularly. *
10. I am physically active and still unable to lose mid-section weight. (example: do you Hit a wall in your workouts) *
11. I encounter muscle fatigue or weakness in situations I normally would not? (examples: knees hurt from walking distances, muscles hurt from coming up stairs, unable to carry things as long) *
12. My abdominal region is regularly swollen or bloated. *
Questions about mind & mood
13. I experience memory loss and cognitive delays. (example: Takes longer to remember events, Problems with word association and recollection) *
14. My doctor recommended anti-depressants and I have had no history of depression. *
15. I have been increasingly irritable or aggressive, especially during premenstrual syndrome *
16. I have recently experienced anxiety or anger, climaxing in outbursts of panic or rage. *
Gynecological questions
17. I experience bleeding irregularities. *
18. I encounter pain during intercourse or decreased libido. *
19. I am having more frequent urinary infections. *
20. I am experiencing vaginal dryness. *
Please provide us with your contact information. in order to receive your Quiz results.
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