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About
Shop
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Franchise
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Contact Us

Home
About
Shop
Phase Calculator
Franchise
Reviews
Contact Us

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About
Shop
Phase Calculator
Franchise
Reviews
Contact Us

Sweet Bliss by Yams – Women's Health & Nutrition Questionnaire

Ready to take the first step towards balanced wellness? Fill out our questionnaire and let us create personalized bites just for YOU!

📋 Contact Information

Full Name

Age

Email Address

Street Address

Apartment Name

City

Zip Code

Phone Number

🏥 Hormonal Health Assessment

Hormonal imbalances can impact overall well-being. Please provide details about your condition and symptoms.

Have you been diagnosed with any of the following conditions?

PCOS (Polycystic Ovary Syndrome) PCOD (Polycystic Ovarian Disease) Hormonal Imbalance PMS None of the above

Are you experiencing any of the following symptoms? (Select all that apply)

Acne Hair fall Weight gain or difficulty losing weight Irregular periods Excess facial or body hair (hirsutism) Fatigue Mood swings or anxiety Bloating or digestive issues None of the above

Are you going through any of these stages?

Planning to get pregnant Pregnancy Post-pregnancy (Baby is less than 2 years old) Perimenopause Menopause Post Menopause None

📅 Menstrual Cycle Details

When did your last menstrual cycle start?

When did your last menstrual cycle end?

How would you describe your menstrual cycle?

Regular (22-35 days) Irregular (Varies significantly) Short Cycle (Less than 20 days) Absent (Missed periods for 3+ months)

Do you experience any of these menstrual symptoms? (Select all that apply)

Severe cramps Heavy bleeding Clotting Bloating Breast tenderness Body ache

Do you know what the follicular and luteal phases of the menstrual cycle are?

Yes Partially No

Do you adjust your diet (seeds, nuts, and nutrients) according to these phases?

Yes, I follow a seed cycling routine No, but I would love to learn more No, I eat the same diet throughout my cycle

🥗 Diet and Nutrition

Proper nutrition is key to hormone balance. Let us know your dietary habits.

How do you prefer to consume seeds?

Raw Roasted Soaked Other

Do you measure your seed intake?

Yes No Sometimes

Are you aware that some seeds can have a heating effect on the body?

Yes No

Would you prefer a readymade, delicious, and nutritious option that removes the hassle while ensuring balanced nutrition?

Yes No

🍫 Dietary Preferences & Allergies

Your dietary preferences help us craft snacks that are both nutritious and enjoyable for you and your family.

Which sweetener do you prefer in your healthy bites? (Select any Two)

Peanut butter Dates Jaggery Dark Chocolate None of the above

Do you have any food allergies? (Select all that apply)

Nut Allergies Sesame Seeds Berries Allergies Gluten Allergy Lactose Intolerance Dates allergy Figs Allergy None

Others

Do you have any other health conditions we should be aware of? (Select all that apply)

Diabetes Thyroid Disorders Hypertension Anemia Arthritis None of the above

Others

📝 Additional Information

Please use this space to share any other relevant information about your health or period cycle:

Would you like us to contact you with your personalized nutritional bites plan?

Yes No

Please provide your preferred contact details below (Email/WhatsApp number):

I acknowledge that I have read and understood the privacy agreement and consent to the use of my responses for nutritional analysis. *

I confirm that the information provided is true and accurate to the best of my knowledge. I understand that any false or misleading information is my responsibility. *

Seed Bliss by Yams

Empowering women’s hormonal health naturally through food-based solutions.

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