Menstrual Distress Questionnaire
Please complete this form to help assess the symptoms and impact of your menstrual cycle. Your responses are confidential and will be used to better understand your experience.
Full Name
*
First Name
Last Name
Age
*
Email Address
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
How would you describe your menstrual cycle?
*
Regular
Irregular
Unsure
On average, how many days does your period last?
*
How severe are the following symptoms during your menstrual cycle?
*
Rows
Not at all
Mild
Moderate
Severe
Cramps or abdominal pain
1
2
3
4
Backache
5
6
7
8
Headache
9
10
11
12
Breast tenderness
13
14
15
16
Bloating
17
18
19
20
Fatigue or low energy
21
22
23
24
Irritability or mood swings
25
26
27
28
Anxiety or nervousness
29
30
31
32
Depression or sadness
33
34
35
36
Difficulty concentrating
37
38
39
40
Sleep disturbances
41
42
43
44
Increased appetite or cravings
45
46
47
48
How often do you experience the following behaviors or changes during your period?
*
Rows
Never
Sometimes
Often
Always
Missed work or school
49
50
51
52
Reduced physical activity
53
54
55
56
Social withdrawal
57
58
59
60
Changes in daily routine
61
62
63
64
Overall, how would you rate the impact of your menstrual symptoms on your daily life?
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Do you use any methods to manage menstrual symptoms?
Pain medication (over-the-counter)
Prescription medication
Heating pads or patches
Dietary changes
Exercise
Other
Please share any additional comments or experiences related to your menstrual cycle.
Submit
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