What is your primary reason for considering hormone therapy? Hot flashes and night sweats Vaginal dryness or discomfort during intercourse Mood swings or depression Osteoporosis prevention Other None How severe are your menopause symptoms? Mild Moderate Severe None Have you discussed your symptoms and medical history with your healthcare provider? Yes, in detail Yes briefly No None Do you have a history of any of the following conditions? (Choose all that apply) Breast cancer Heart disease Blood clots Stroke None of the above None How concerned are you about the potential side effects of hormone therapy? Not concerned Slightly concerned Very concerned None What is your attitude towards alternative treatments (e.g., lifestyle changes, herbal remedies)? Prefer hormone therapy over alternatives Open to both hormone therapy and alternatives Prefer alternatives over hormone therapy None What is your current age? Under 50 50-59 60-69 70 or older None 1 out of 2 Name Email Phone Time's up
