SurveyMonkey Powered Online Survey

Thank you for your interest in joining the MyMenopauseTeam private beta, a social network for women going through menopause. The purpose of this short survey is to learn more about your life with menopause. We will be in touch over the coming months for additional feedback as we build out features for MyMenopauseTeam.

ALL OF YOUR ANSWERS TO THIS SURVEY WILL BE KEPT COMPLETELY CONFIDENTIAL.

Question Title

* Please tell us about you and where you're from below. (We will not share your information. The information you provide below is completely confidential).

Name:

City/Town:

State:

Email Address:

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* When is your birthday?

Input values (ex. 05/23/1964)

Date

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* When did you begin experiencing menopause symptoms? (approximate date)

Input values (ex. 05/23/1964)

Date

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* Do you have any conditions that can cause or hasten menopause?

Hysterectomy

Medications for cancer, endometriosis, or other conditions

Radiation treatment for cancer

Premature ovarian insufficiency/failure

Epilepsy

Autoimmune disease

Family history of premature menopause

Other (please specify what best describes you)