PMDD Screening Survey
Please complete this survey to help assess symptoms related to Premenstrual Dysphoric Disorder (PMDD). Your responses are confidential and will be used for screening purposes only.
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How would you describe your menstrual cycle?
*
Regular (cycles occur at consistent intervals)
Irregular (cycles vary in length)
Not sure
Other
How many days does your typical menstrual cycle last?
*
Please Select
21-24 days
25-28 days
29-32 days
More than 32 days
Not sure
During the week before your period, how much have you experienced the following symptoms?
*
Rows
Not at all
Mild
Moderate
Severe
Mood swings
1
2
3
4
Irritability or anger
5
6
7
8
Depressed mood or hopelessness
9
10
11
12
Anxiety or tension
13
14
15
16
Decreased interest in usual activities
17
18
19
20
Difficulty concentrating
21
22
23
24
Fatigue or lack of energy
25
26
27
28
Changes in appetite
29
30
31
32
Sleep disturbances
33
34
35
36
Physical symptoms (breast tenderness, headaches, joint or muscle pain, bloating)
37
38
39
40
How much do these symptoms interfere with your daily life (work, school, social activities, relationships)?
*
No interference
1
2
3
4
Extreme interference
5
1 is No interference, 5 is Extreme interference
Have you ever been diagnosed with a mood or anxiety disorder?
*
Yes
No
Not sure
Is there anything else you would like to share about your symptoms or menstrual cycle?
Submit Survey
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