Premenstrual Symptom Screening Questionnaire
Please complete this questionnaire to help assess your premenstrual symptoms and their impact.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Phone Number (optional)
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
Average length of your menstrual cycle (in days)
*
Please indicate how much you experience the following symptoms in the week before your period (Premenstrual Phase):
*
Rows
Not at all
Mild
Moderate
Severe
Mood swings
1
2
3
4
Irritability or anger
5
6
7
8
Depressed mood
9
10
11
12
Anxiety or tension
13
14
15
16
Breast tenderness
17
18
19
20
Bloating
21
22
23
24
Headaches
25
26
27
28
Fatigue or low energy
29
30
31
32
Sleep disturbances
33
34
35
36
Food cravings or increased appetite
37
38
39
40
How much do your premenstrual symptoms interfere with your daily life or activities?
*
Not at all
0
1
2
3
4
5
6
7
8
9
Extremely
10
0 is Not at all, 10 is Extremely
Do you take any medication or supplements to manage premenstrual symptoms?
*
Yes
No
If yes, please list the medications or supplements you use (optional)
Is there anything else you would like to share about your premenstrual symptoms? (optional)
Submit
Should be Empty: