Questionnaire about Perimenopause Symptoms

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  

How would you describe your menstrual flow?

Light   Moderate   Heavy  

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

None   Small   Medium   Large   

Do you experience abdominal cramp during your periods?

None   Mild   Moderate   Severe   

What symptoms of perimenopause are you are experiencing?

Period changes  Hot flashes and night sweats  Vaginal dryness  Trouble sleeping 
Mood swing   Depression   Anxiety  Fatigue 
Headache  Thinning hair  Loss of libido  WWeight gain 
Forgetfulness  
Others symptoms (please specify):

Have you been diagnosed with any disorders of the pelvic area ?

Yes (please specify):
No

Are you under any medication?

Yes   If Yes, please specfy:
No  

How did you hear about us?

Internet Friends Health Practioner Other
If "Other", please specify: (Google, WebMD, etc..)

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

Attachment:

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