Adolescent Menstrual Health Intake Form
Please complete this form to help us understand your menstrual health and provide appropriate support.
Full Name
*
First Name
Last Name
Age
*
Email Address (for follow-up, if needed)
example@example.com
Phone Number (for follow-up, if needed)
Please enter a valid phone number.
Format: (000) 000-0000.
At what age did your periods start (first menstruation)?
How would you describe your menstrual cycle?
*
Regular (predictable timing)
Irregular (unpredictable timing)
Not sure
On average, how many days does your period last?
Do you experience any of the following symptoms during your period? (Select all that apply)
Cramps or abdominal pain
Heavy bleeding
Headaches
Mood changes
Nausea
Other
Do you have any concerns or questions about your periods or menstrual health?
Would you like to be contacted for follow-up or support?
Yes, by email
Yes, by phone
No, not at this time
Submit
Should be Empty: