Menstrual History Questionnaire
Please complete this questionnaire to help us understand your menstrual and reproductive health history.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
example@example.com
Age at first period (menarche)
*
How regular are your menstrual cycles?
*
Regular (every 21-35 days)
Irregular
No periods
Average length of your menstrual cycle (in days)
*
How many days does your period usually last?
*
How would you describe your menstrual flow?
*
Light
Moderate
Heavy
Do you experience any of the following symptoms with your periods? (Select all that apply)
Cramps
Headaches
Nausea
Mood changes
Breast tenderness
Other
Have you ever been pregnant?
*
Yes
No
Are you currently using any form of contraception?
*
Yes
No
If yes, please specify the type of contraception used
Do you have any diagnosed reproductive health conditions?
Polycystic Ovary Syndrome (PCOS)
Endometriosis
Fibroids
None
Other
Is there anything else about your menstrual or reproductive health you would like to share?
Submit
Should be Empty: