PMDD Symptom Assessment Form
Please answer the following questions to help assess your PMDD symptoms. Your responses will help provide a clearer picture of your experiences over the past month.
How often have you experienced significant mood changes in the week before your period?
*
Never
Rarely
Sometimes
Often
Almost always
Please rate the severity of the following symptoms in the week before your period.
*
Rows
Not at all
Mild
Moderate
Severe
Irritability or anger
1
2
3
4
Anxiety or tension
5
6
7
8
Depressed mood or hopelessness
9
10
11
12
Mood swings
13
14
15
16
Fatigue or low energy
17
18
19
20
How much have your symptoms interfered with your daily life or activities?
*
Not at all
1
2
3
4
Extremely
5
1 is Not at all, 5 is Extremely
Which of the following physical symptoms have you noticed before your period? (Select all that apply)
*
Breast tenderness
Headaches
Bloating
Joint or muscle pain
Other
During which phase of your menstrual cycle do your symptoms usually begin?
*
1-2 weeks before period
A few days before period
During period
After period
Not sure
How would you rate your overall mood in the week before your period?
*
1
2
3
4
5
Have you noticed a clear improvement in symptoms after your period starts?
*
Yes
No
Not sure
How many days do your symptoms typically last each month?
*
Do you track your symptoms each month?
*
Yes, regularly
Sometimes
No
Is there anything else you would like to share about your symptoms or experiences?
Submit Assessment
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