Questionnaire

Full Name

Age

Email Address

Phone Number

Country

What condition(s) are you seeking support for? (Check all that apply)

PCOS (Polycystic Ovary Syndrome)

Endometriosis

Fibroids

Infertility

How long have you been experiencing these symptoms or been diagnosed?

Deselect Answer

Less than a year

1–3 years

Over 3 years

None

What symptoms are you currently experiencing? (Check all that apply)

Irregular periods

Weight gain or difficulty losing weight

Excess facial or body hair

Thinning hair on the scalp

Acne or oily skin

Severe menstrual cramps or pelvic pain

Pain during intercourse

Heavy or irregular periods

Bloating or digestive issues

Heavy or prolonged menstrual bleeding

Pelvic pain or pressure

Frequent urination

Constipation or bloating

Difficulty conceiving

History of miscarriages

Known ovulation issues

Have you been formally diagnosed with any of the above conditions?

Deselect Answer

Yes

None

10.

Are you currently undergoing any treatments for your condition(s)?

11.

Have you had any surgeries or medical procedures related to your condition(s)?

Comment

12.

Are you currently taking any medications or supplements?

13.

Do you have any known allergies or sensitivities to herbs, medications, or foods?

14.

How would you describe your current diet?

Deselect Answer

Balanced and healthy

Moderate (some healthy choices, but room for improvement)

Unbalanced (frequent processed or unhealthy foods)

None

15.

Do you follow any specific dietary restrictions?

Deselect Answer

Vegetarian

Gluten-free

Dairy-free

None

16.

How often do you engage in physical activity?

Deselect Answer

Rarely

1–2 times a week

3–5 times a week

Daily

None

17.

What are your primary health goals?

Deselect Answer

Balance hormones naturally

Manage or reduce symptoms

Improve fertility

Support overall wellbeing

Avoid invasive medical procedures

None

18.

Have you tried herbal or natural remedies before?

Comment

19.

Do you have any specific concerns or questions about using herbal treatments?

20.

Consent and Disclaimer

By submitting this form, I acknowledge that the herbal treatment provided is designed to support natural processes and is not intended to replace professional medical care.

I understand that results may vary, and I accept responsibility for my own health decisions.Deselect Answer

Yes

None

Hint

1 out of 4

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