CleopatraRX PCC Script Follow-UP Question Title * 1. Prescription Stage Follow-Up Baseline 3-Month 6-Month 12-Month 18-Month 24-Month Question Title * 2. Name Name City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 3. Date of Birth Month/Day/Year Date Question Title * 4. Please select an option below that best describes your menstrual cycle. I have regular periods I have irregular periods My periods stopped within the past 6 months My periods stopped completely over 6 months ago. N/A Other (please specify) Question Title * 5. Since beginning PearlPAK, have you noticed a change in your menstrual cycle? I have regular periods I have irregular periods My periods stopped within the past 6 months My periods stopped completely over 6 months ago. N/A Other (please specify) Question Title * 6. Have you had surgical menopause? Yes, uterus removed (hysterectomy), both ovaries still present Yes, both ovaries removed (ovariectomy/oophorectomy), uterus still present Yes, uterus and both ovaries removed Yes, only one ovary removed (partial ovariectomy/oophorectomy), uterus and other ovary still present Yes, uterus and one ovary removed, one ovary present No, I still have uterus and both ovaries. Not sure. N/A Other (please specify) Question Title * 7. If you answered Yes to the previous question, approximately what year did you have surgery? [select year]. Less than 1 year ago. Less than 5 years ago. Between 5 and 10 years ago. Over 10 years ago. Not applicable, I answered No N/A Other (please specify) Question Title * 8. Since beginning PearlPAK, have you had surgical menopause? Yes, uterus removed (hysterectomy), both ovaries still present Yes, both ovaries removed (ovariectomy/oophorectomy), uterus still present Yes, uterus and both ovaries removed Yes, only one ovary removed (partial ovariectomy/oophorectomy), uterus and other ovary still present Yes, uterus and one ovary removed, one ovary present No, I still have uterus and both ovaries. Not sure. N/A Other (please specify) Question Title * 9. If you answered Yes to the above question, month and year. Question Title * 10. Are you having symptoms of menopause? Yes No Not Sure Other (please specify) Question Title * 11. What symptoms of menopause have you noticed? Hot flashes (including but not limited to night sweats or day sweats) Problem sleeping Tired during the day Poor sexual function Skin aging None (I answered No) All of the Above N/A Other (please specify) Question Title * 12. Since beginning PearlPAK, what symptoms of menopause are you experiencing? Hot flashes (including but not limited to night sweats or day sweats) Problem sleeping Tired during the day Poor sexual function Skin aging None (I answered No) All of the Above N/A Other (please specify) Question Title * 13. Do you have problems with brain fog (your thinking is not like it was 10 years ago)? Yes No Not Sure Other (please specify) Question Title * 14. How do you rate this difficulty in brain fog (as compared to 10 years ago)? Severe difficulty (50% worse or more) Moderate difficulty (25% worse) Mild difficulty (10% worse or less) No difficulty N/A Other (please specify) Question Title * 15. Since beginning PearlPAK, how do you rate this difficulty in brain fog? Severe difficulty (50% worse or more) Moderate difficulty (25% worse) Mild difficulty (10% worse or less) No difficulty N/A Other (please specify) Question Title * 16. Are you having difficulty concentrating (as compared to 10 years ago)? Yes No Not Sure Other (please specify) Question Title * 17. How do you rate this difficulty in concentrating (as compared to 10 years ago)? Severe difficulty (50% worse or more) Moderate difficulty (25% worse) Mild difficulty (10% worse or less) No difficulty N/A Other (please specify) Question Title * 18. Since beginning PerlPAK, how do you rate this difficulty in concentrating? Severe difficulty (50% worse or more) Moderate difficulty (25% worse) Mild difficulty (10% worse or less) No difficulty N/A Other (please specify) Question Title * 19. Are you having difficulty in remembering things (as compared to 10 years ago)? Yes No Not Sure Other (please specify) Question Title * 20. How do you rate this difficulty in remembering things (as compared to 10 years ago)? Severe difficulty (50% worse or more) Moderate difficulty (25% worse) Mild difficulty (10% worse or less) No difficulty N/A Other (please specify) Question Title * 21. Since beginning PearkPAK, how do you rate this difficulty in remembering things? Severe difficulty (50% worse or more) Moderate difficulty (25% worse) Mild difficulty (10% worse or less) No difficulty N/A Other (please specify) Question Title * 22. Are you having difficulty in processing new information quickly? (as compared to 10 years ago)? Yes No Not Sure Other (please specify) Question Title * 23. How do you rate this difficulty in processing new information quickly? (as compared to 10 years ago)? Severe difficulty (50% worse or more) Moderate difficulty (25% worse) Mild difficulty (10% worse or less) No difficulty N/A Other (please specify) Question Title * 24. Since beginning PearkPAK how do you rate this difficulty in processing new information quickly? Severe difficulty (50% worse or more) Moderate difficulty (25% worse) Mild difficulty (10% worse or less) No difficulty N/A Other (please specify) Question Title * 25. Are you having difficulty in finding the right words during conversations? (as compared to 10 years ago)? (as compared to 10 years ago)? Yes No Not Sure Other (please specify) Question Title * 26. How do you rate this difficulty in finding the right words during conversations (as compared to 10 years ago)? Severe difficulty (50% worse or more) Moderate difficulty (25% worse) Mild difficulty (10% worse or less) No difficulty N/A Other (please specify) Question Title * 27. Since beginning PearlPAK how do you rate this difficulty in finding the right words during conversations? Severe difficulty (50% worse or more) Moderate difficulty (25% worse) Mild difficulty (10% worse or less) No difficulty N/A Other (please specify) Question Title * 28. Are you having difficulty with problem solving? (as compared to 10 years ago)? Yes No Not Sure Other (please specify) Question Title * 29. How do you rate this difficulty in problem solving (as compared to 10 years ago)? Severe difficulty (50% worse or more) Moderate difficulty (25% worse) Mild difficulty (10% worse or less) No difficulty N/A Other (please specify) Question Title * 30. Since beginning PearkPAK, how do you rate this difficulty in problem solving? Severe difficulty (50% worse or more) Moderate difficulty (25% worse) Mild difficulty (10% worse or less) No difficulty N/A Other (please specify) Question Title * 31. Have you ever taken hormones for menopause? (estrogen, progesterone, Premarin, PremPro, hormone pellet therapy) Never previously, but not now yes, currently not sure Other (please specify) Question Title * 32. If yes to question above, which medication, dose, method of administration (oral, transdermal, subcutaneous) how long did you take it, how long ago did you stop HRT? Question Title * 33. Do you have cancer or a history of cancer, stroke, heart disease, paralysis, clotting disorder, or other serious illness? Yes No Not Sure Other (please specify) Question Title * 34. Since beginning PearlPAK, have you been diagnosed with cancer, stroke, heart disease, paralysis, clotting disorder, or other serious illness? Yes No Not Sure N/A Other (please specify) Question Title * 35. Approximately what is your highest level of education (since this can affect brain fog)? Less than 12 years 12 years (total years or high school grad or GED) 16 years (total years or college grad) More than 16 years (master's or other advanced degree or other total years of education) Other (please specify) Question Title * 36. How would you rate your overall quality of life now on a scale from 1-10? (10=great, 5=fair, 1=poor) poor fair great Clear i We adjusted the number you entered based on the slider’s scale. Done