Questionnaire about Premenstrual Symdromes

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 clots 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 premenstrual syndrome symptoms are you experiencing ?

Depression	mood swing	Anxiety	Loss of Concentration
Fatigue	Food Craving	trouble sleeping	Headache
Breast Tenderness	WaterRetention	Acne Flare Up	Constipation
Diarrhea

Others: Specify:

Do you have any disorders of the pelvic area that might be related to your premenstrual syndrome (PMS)?

Yes (please specify):
No

Are you currently taking any medication?

No   Yes (please specify):

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:

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