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Questionnaire about Absent Periods

Please answer a few questions in order that we can better understand your situation.**

Your Name:


Your Email Address:


Verify Email Address:





What was the date of your last period?

How many months ago did your period stop?

How many days are there between your periods usually?

Less than 25 days   25 to 32 days   33 to 42 days   More than 42 days  

For how many days do your periods usually last?

3 to 6 days   7 to 10 days   More than 10 days  

Do you experience blood clots in your menstrual flow, and if so, how large are they?

None   Small   Medium   Large   

Did you experience abnormal cramp during your menstrual periods?

None   Mild   Moderate  Severe  

If yes, when do the cramps usually occur? Before period  During period  After period 

Have you being diagnosed with any disorders of the uterus that might  be related to your absent periods?

Yes,  please specify:

How did you hear about us?

If "Other", please specify: (Google, WebMD, etc..)

If you have any further comments or questions, please write these in the box below.


We guard your personal information with the strictest of confidentiality. Please view our privacy policy to learn more.

**Although our herbal doctors are ready to answer your questions, we cannot provide medical advice online. Your own medical doctor, who knows your clinical history, is the only person qualified to give you medical advice – we can only guide your use of our products and suggest how our products may be able to benefit you in your personal situation.

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