Membership Survey

Help us understand your health and wellness goals

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Let's Get Started

How old are you? *

18-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65+

Energy & Exercise

How would you rate your overall energy? *

Very Low - Constantly Tired

Low - Tired Most Days

Moderate - Some Good and Bad Days

Good - Generally Energetic

Excellent - Very Energetic

How often do you currently exercise? *

Never or rarely

1-2 times a week

3-4 times a week

5-6 times a week

Daily

What type of exercise do you prefer or would like to try? *

Low-impact - Walking, swimming, yoga

Strength training - Resistance exercises

Cardio - High-intensity workouts

Flexibility & balance - Yoga, pilates

Mixed activities - A variety of different exercises

Diet & Wellness

How would you rate your current diet? *

Poor - Mostly processed foods

Fair - Some healthy choices

Good - Mostly healthy with occasional treats

Excellent - Very healthy and balanced

Do you have any dietary restrictions or preferences? *

No restrictions

Vegetarian

Vegan

Gluten-free

Dairy-free

How is your sleep quality? *

Very Poor - Frequent wake-ups, hard to fall asleep

Poor - Some sleep issues

Fair - Occasional sleep problems

Good - Generally sleep well

Excellent - Sleep soundly most nights

How would you rate your stress levels? *

Very High - Constantly overwhelmed

High - Frequently stressed

Moderate - Manageable stress

Low - Rarely stressed

Very Low - Very calm and relaxed

Medical & Goals

Do you have any existing medical conditions? (Select all that apply)

Diabetes

High Blood Pressure

Thyroid disorders

Heart disease

Osteoporosis

None of the above

Do you take any medications? *

None

Hormone therapy

Supplements

Prescription medication

Other

Do you have any allergies?

What is your primary health goal? (Select all that apply)

Manage menopause symptoms

Improve energy and vitality

Better sleep quality

Balance mood and emotional well-being

Overall wellness and prevention

What approaches interest you most? (Select all that apply)

Natural remedies and supplements

Lifestyle and diet changes

Exercise and movement

Mindfulness and stress management

Medical treatments and consultations

Which types of affirmations inspire you? (Select 3) *

Health

Confidence

Calmness

Motivation

Resilience

Symptoms

Which symptoms are you experiencing? (Select all that apply)

Hot Flashes

Joint Pain

Cognitive Decline

Night Sweats

Bone Loss

Brain Fog

Insomnia

Weight Gain

Memory Loss

Fatigue

Vaginal Dryness

Stiffness

Hormonal Shifts

Painful Sex

Heart Risk

Irregular Periods

Low Libido

Hair Loss

Mood Swings

Urinary Issues

Stress Intolerance

Anxiety

UTIs

Low Confidence

Depression

Skin Changes

Sensitivity

Irritability

Muscle Weakness

✓

Thank You!

Your survey has been submitted successfully. We'll be in touch soon!

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Your Personalized Affirmations

Here are some affirmations tailored just for you

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Your Personalized Recommendations

Based on your survey responses, here are our recommendations for you

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We'd Love Your Feedback!

Help us improve EmpressHealth.ai by sharing your thoughts

How interested would you be in using EmpressHealth.ai? *

Very Interested Interested Somewhat Interested Not Interested

Which features are important to you? Select all that apply *

24/7 AI-assisted chatbot — Instant support and guidance answers Connect with doctors, therapists, and holistic experts — Trusted healthcare professionals Personalized wellness recommendations — Informed advice based on your unique health Daily affirmations and mood support — Positive mindset content for mental wellbeing Curated marketplace of menopause products — Quality products for your journey Symptom tracking + progress insights — Monitor your health journey with detailed analytics Digital journal for mood & health tracking — Private space to record thoughts and patterns

How likely would you be to register as a regular user once the platform launches? *

1 - Very Unlikely 2 3 4 5 - Very Likely

Would you recommend Empress Health to others? *

Yes No Maybe

Subscription Tiers *

VIP — $49/month Premium — $39/month Plus — $25/month $9/month – Essential I would not pay