Please Take Our SURVEY...
If Your Information Is Selected, You Could Win A Three Month Supply Of
Imperial Gold Maca™ Valued At $100.00 Or A Vitamin & Mineral Shopping Spree Valued At $75.00

Do You Use Alternative Medicine for Any Of These Symptoms and Concerns ?

Menopause, Peri-Menopause, Thyroid Condition, Fibromyalgia, Erectile Dysfunction, Impotence, General Fatigue, Hormonal Imbalance, Chronic Fatigue Syndrome, Hot Flashes, Night Sweating, Low Sexual Interest.

YOUR ANSWERS ARE CONFIDENTIAL AND WILL NOT BE SHARED WITH ANYONE ELSE.

Have You Had Symptoms or Concerns Within the Past Year? If So, Please Take Our Survey.
What Are You Doing For Your Symptoms or Concerns? Hormone Therapy Alternative Therapy Both Therapies Neither Therapy Auyervada Herbs Prescription Medications
If You Have Used Alternative Therapy, or Both Therapies Please Select From The Following List of Symptoms or Concerns. Choose the Alternative Treatments you Have Used.
SYMPTOMS:
Hot Flashes Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
Period Changes Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
Anxiety Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
Fatigue Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Die	Exercise Acupuncture Relaxation/Meditation Homeopathy
Mood Swings Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
Forgetfulness Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
Insomnia Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
Weight Gain Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
Vaginal Dryness Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
Headache Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
Night Sweats Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
Depression Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
CONCERNS:
Osteoporosis Yes No	Select Treatments: Herbs (Which Ones) Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
Heart Disease Yes No	Select Treatments: Herbs Calcium Vitamin/supplement other than Calcium Proper nutrition/Diet	Exercise Acupuncture Relaxation/Meditation Homeopathy
ADDITIONAL COMMENTS ?

Do You Have A Personal Experience You Want To Share ? Yes No

DEMOGRAPHICS:
Age		Race
Education		Household Income
State/Country

E-Mail Address

OPTIONAL

Your First Name

Disclaimer

Please Take Our SURVEY... If Your Information Is Selected, You Could Win A Three Month Supply Of Imperial Gold Maca™ Valued At $100.00 Or A Vitamin & Mineral Shopping Spree Valued At $75.00

Menopause, Peri-Menopause, Thyroid Condition, Fibromyalgia, Erectile Dysfunction, Impotence, General Fatigue, Hormonal Imbalance, Chronic Fatigue Syndrome, Hot Flashes, Night Sweating, Low Sexual Interest.