Menopause Nutrition Intake Form
Please complete this form to help us understand your nutrition habits, symptoms, and preferences related to menopause.
Full Name
*
First Name
Last Name
Age
*
Which menopause-related symptoms are you currently experiencing?
Hot flashes
Night sweats
Mood changes
Sleep disturbances
Weight changes
Low energy
Other
Describe your typical daily eating pattern (meals, snacks, timing).
*
Do you have any dietary restrictions or food allergies?
Vegetarian
Vegan
Gluten-free
Dairy-free
Nut allergy
None
Other
How would you describe your current hydration habits?
Very good (8+ cups/day)
Good (6-8 cups/day)
Fair (3-5 cups/day)
Poor (less than 3 cups/day)
Are you currently taking any nutrition supplements?
Yes
No
How would you describe your physical activity level?
Sedentary
Lightly active
Moderately active
Very active
What are your main nutrition-related goals during menopause?
Is there anything else you would like to share about your nutrition or menopause experience?
Submit
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