Questionnaire about Heavy Menstrual Bleeding

Your Name:
Your Email Address:
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Age:
Race:	White Black Asian American Indian Pacific Islander Other
Weight:	(pounds)

What was the date of your last period?

Usually, how many days are there between your periods?

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  

For how many days of your period would you describe the flow as “heavy”?

1 to 2 days   3 to 5 days   More than 6 days  

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

None   Small   Medium   Large   

Do you experience abdominal cramp during your menstrual periods?

None   Mild   Moderate  Severe  

If yes, when? Before Period  During Period  After Period 

Do you use a contraceptive intrauterine device (IUD) ?

Yes   No  

Do you have anemia?

Yes   No  

Do you have any disorders of the uterus that might be related to your heavy menstrual bleeding ?

Yes,  please specify:
No

Are you currently undergoing any medical treatment ?

No   Yes (please specify)

How did you hear about us?

Internet Friends Health Practioner Other
If “Other”, please Specify: (Google, WebMD, etc..)

Please add any comments and questions you have below:

Attachment:

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