FIRST NAME *

SURNAME *

MOBILE NUMBER *

EMAIL ADDRESS *

Location * Abra Agusan del Norte Agusan del Sur Aklan Albay Antique Apayao Aurora Basilan Bataan Batanes Batangas Benguet Biliran Bohol Bukidnon Bulacan Cagayan Camarines Norte Camarines Sur Camiguin Capiz Catanduanes Cavite Cebu Cotabato Davao de Oro (Compostela Valley) Davao del Norte Davao del Sur Davao Occidental Davao Oriental Dinagat Islands Eastern Samar Guimaras Ifugao Ilocos Norte Ilocos Sur Iloilo Isabela Kalinga La Union Laguna Lanao del Norte Lanao del Sur Leyte Maguindanao Marinduque Masbate Metro Manila Misamis Occidental Misamis Oriental Mountain Province Negros Occidental Negros Oriental Northern Samar Nueva Ecija Nueva Vizcaya Occidental Mindoro Oriental Mindoro Palawan Pampanga Pangasinan Quezon Quirino Rizal Romblon Samar Sarangani Siquijor Sorsogon South Cotabato Southern Leyte Sultan Kudarat Sulu Surigao del Norte Surigao del Sur Tarlac Tawi-Tawi Zambales Zamboanga del Norte Zamboanga del Sur Zamboanga Sibugay

CITY (if within Metro Manila) Caloocan Las Piñas Makati Malabon Mandaluyong Manila Marikina Muntinlupa Navotas Parañaque Pasay Pasig Pateros Quezon City San Juan Taguig Valenzuela

Gender * Man Woman Others Prefer not to respond

Age *

MOST BOTHERSOME MENOPAUSAL SYMPTOM * Irregular periods Skin dryness Sleep disturbance Low energy and fatigue Mood swings Hot flushes Night sweats Irritability Lower sex drive Anxiety and a feeling of loss Vaginal dryness Increased susceptibility to vaginal and urinary infections Joint and muscle aches Depression Weight gain Changes in hair luster Others

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