Circuit Breaker Screening Test - My Menopause Transformation

MyMT™ Circuit Breaker Health Screening Form

Step 1: Please complete the MyMT™ Health Screen and Submit this to Wendy

When this is submitted your exclusive member access isntructions will be sent to you. Wendy will respond to your screening form if required.

Do you have a family history of heart disease or strokes? *

Yes No

Has your doctor ever said that you have a heart condition or have you ever suffered a stroke? *

Yes No

Do you feel unexplained pain in your chest at rest or when you do physical activity? *

Yes No

Do you ever lose your balance because of dizziness during physical activity? *

Yes No

Have you had an asthma attack requiring medical attention at any time over the last 12 months? *

Yes No

If you have diabetes, have you had trouble controlling your blood glucose at any time over the last 6 months? *

Yes No

Do you have a bone or joint problem that could be made worse by participating in exercise? *

Yes No

Do you have any other medical condition that may prevent you from undertaking exercise? *

Yes No

Is your blood pressure - over 140mm Hg systolic or 90mm Hg diastolic. Or are you on blood pressure medication? *

Yes No

Are you currently taking Hormone Replacement Therapy (HRT) or Bio-identical Hormone Therapy? *

Yes No

Do you have gut health or digestion issues? *

Yes No

Please indicate your current Sleep Patterns

Sleep hours per day on average *

Less than 4 hours per night Between 4-6 hours night Sleep soundly for 6-8 hours

Do you have intermittent sleep with night sweats and/or hot flushes? *

Yes No

Please indicate your current energy and mood levels:

I am frequently tired *

Yes No

I have fluctuating energy levels during the day *

Yes No

I have frequent mood swings *

Yes No

I often feel depressed *

Yes No

I am already on anti-depressant medication *

Yes No

Body Types:

What is your nearest body-type? *

Pituitary Entire Gain Thyroid Gain Gonad body-type Adrenal Upper Gain

Do you perceive you are overweight? *

Yes No

Waiver:

I acknowledge to the best of my ability that I am in good health and have no known medical problems that would restrict my ability to participate in this programme. *

I agree that at any time I can remove myself from this program. *

I understand that ongoing access to the MyMT™ programme [Coaching Support and Programme Access] is FREE for the first 3 months and costs NZ$12.50 per month thereafter. *

I acknowledge My Menopause Transformation™ as the sole proprietor of this program and agree not to distribute it to any other persons or make copies without the permission of MyMT™. *

First Name *

Last Name *

Email used to purchase programme *

Facebook Name

Facebook name you will use to access the Coaching Support Group (no husbands’ or partners’ accounts please)

Age *

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MyMT™ has been set up for one reason; to help women around the globe proactively manage their own menopause transformation.

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