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DUTCH Survey

Please answer these questions to the best of your ability to help us determine which DUTCH test is right for you! After you submit your responses, we will review them and send you more information on getting started.

*PLEASE NOTE: in order for us to send you more information you must check the box "subscribe to our email list" on the very last page before you hit submit!

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Question 1 of 10

Please provide your email address

Question 2 of 10

Please provide your First and Last Name

 

Question 3 of 10

What is the main reason you are wanting to have your hormones tested?

Question 4 of 10

What hormonal imbalances or symptoms of hormone imbalance are you experiencing?

Question 5 of 10

Are you on birth control? If yes, what kind?

Question 6 of 10

Are you on hormone replacement therapy? If yes, what kind?

Question 7 of 10

Are you struggling with infertility?

A

Yes

B

No

Question 8 of 10

Please mark all that you struggle with:

(Select all that apply)
A

irregular cycles

B

menopause

C

hot flashes

D

infertility

E

weight gain

F

fatigue

G

low libido

H

mood swings

I

depression

J

insomnia/sleep issues

Question 9 of 10

Have you had trauma in your past? 

A

Yes

B

No

C

Maybe

Question 10 of 10

On a scale of 1-10 rate your stress level (1 being no stress, 10 being highly stressful):

Confirm and Submit