HOME - Peter Smanjak

Embrace Your Menopause Journey with Confidence

Menopause can feel like an overwhelming wave of change, but you don’t have to face it alone or let it dim your spirit. With the right interventions, you can ease the struggles, reclaim your energy, and thrive through these transformative years—let’s start by understanding your story today.

First Name

Last Name

Date of Birth (d/m/Y)

Surburb

City

State

Country

Email

Phone no.

Occupation (if applicable)

Job Title

Section I - Your Menopause Journey

Menopause is a unique journey that unfolds differently for every woman. Tell us where you think you are so we can meet you at the right stage.

1. Which stage do you think you’re in? (Check one)


1. Premenopause (regular periods, no major changes)
2. Perimenopause (irregular periods, some symptoms)
3. Menopause (no period for 12+ months)
4. Postmenopause (past menopause, long-term changes)
5. Unsure


6. Not yet
7. Less than 1 year ago
8. 1-3 years ago
9. 4-6 years ago
10. 7+ years ago

Section II: Your Health Actions

You’ve likely taken steps to navigate this transition—big or small. Share what you’ve tried so we can build on your efforts.

3. What have you tried to manage menopause symptoms? (Check all that apply)


11. Nothing yet
12. Diet changes (e.g., less caffeine, more calcium)
13. Exercise (e.g., yoga, walking)
14. Supplements/herbs (e.g., black cohosh, cranberry) Hormone Replacement Therapy (HRT)
15. Doctor visits/medical tests
15. Other (specify below)

4.Have you discussed menopause with a healthcare provider?


16. Yes, regularly
17. Yes, once or twice
18. Still intend too
19. No

If other, please specify:

20. Have you been officially diagnosed as menopausal?

Section 3 – Your Menopause State

Menopause can bring a wide range of symptoms that affect daily life. Let us know what you’re experiencing and how intense it feels.

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
21. Hot flashes
22. Night sweats
23. Irregular periods
24. Mood changes
25. Breast soreness
26. Decreased libido
27. Vaginal dryness
28. Headaches
29. Recurring UTIs
30. Burning mouth
31. Changes in taste
32. Fatigue
33. Acne
34. Digestive changes
35. Joint pain
36. Muscle tension/aches
37. Electric shock sensations
38. Itchiness

	0	1	2	3
39. Sleep disturbance
40. Difficulty concentrating
41. Memory lapses
42. Thinning hair
43. Brittle nails
44. Weight gain
45. Stress incontinence
46. Dizzy spells
47. Allergies
48. Osteoporosis
49. Irregular heartbeat
50. Tinnitus
51. Irritability
52. Depression
53. Anxiety
54. Panic disorder
55. Other (specify below)

If other, please specify:

Using the same KEY scale above, answer the following question:

	0	1	2	3
56. How much do these symptoms disrupt your daily life overall?

Section IV – Section 4: Your Goals

What do you most want to solve or learn through this course? This course is about empowering you to feel your best. Pick the top three areas where you want support or change.


57. Understand my stage and what’s next
58. Reduce specific symptoms (specify below in order of priority)
59. Explore intervention options (e.g., lifestyle, HRT)
60. Improve emotional well-being
61. Connect with others for support


62. Repair my gut health (e.g., reduce bloating, improve digestion)
63. Remove brain fog (e.g., boost focus, memory)
64. Learn to exercise effectively (e.g., for joints, weight)
65. Eat healthier (e.g., menopause-friendly diet)
66. Lose weight (e.g., reverse menopause-related gain)

If to reduce other specific symptoms (specify below in order of priority):

Acknowledgment for Menopause Course Signup Health Questionnaire

By completing this questionnaire, I acknowledge the following:

1. Accuracy of Responses: I confirm that the information I provide is true and accurate to the best of my knowledge, reflecting my current menopause experience.

2. Purpose of Collection: I understand that this questionnaire is designed to tailor my course experience and does not create a formal practitioner-client relationship or guarantee ongoing collaboration.

3. Not a Medical Substitute: I recognize that the course content and any insights offered are educational only and not a substitute for professional medical advice from a qualified healthcare provider.

4. Tailored Support: I understand that the course guidance is designed based on the most common symptoms reported by all participants and may not address my individual responses specifically. For a personalized approach to my unique symptoms, I can seek further assistance from a practitioner.

I acknowledge the above and consent to have this website store my submitted information so they can respond to my inquiry.