Which of these best describes your menstrual cycle CURRENTLY?
A.
Period comes every 25-35 days
B.
Period comes every 24 days or less
C.
Period comes every 36 days or more
D.
My period is irregular
E.
I currently don’t get my period
2.
How many days does your period last (not including spotting before and after your period)?
A.
I usually just spot and don’t have a flow
B.
2 days or less
C.
3-7 days
D.
8 days or more
3.
How often do you change pads, tampons or your menstrual cup?
A.
Once a day or less
B.
More often than every 1-2 hours
C.
Every 3-4 hours
4.
At the beginning and during my period, I experience:
A.
No cramps
B.
Mild to medium cramps
C.
Ouch! Severe cramps
5.
What color is your period blood?
A.
Starts brown or darker and stays that way
B.
Starts out brown or darker and turns red
C.
Starts out red and stays that way
D.
Lighter in color (pink/light red) & turns red
E.
Lighter in color (pink/light red) the whole time
6.
Do you experience breakthrough bleeding or spotting outside of your actual period?
A.
Yes, 3-7 days (or more) before my period
B.
Yes, I spot around ovulation
C.
Yes, around ovulation & before my period
D.
I spot at other times in my cycle
E.
No, I don’t experience any spotting
7.
Are you currently using hormonal contraceptives/birth control? (This includes the birth control pill, patch, IUD, implant, & Nuvaring)
A.
Yes, I am on hormonal birth control
B.
No, I stopped it LESS THAN 6 months ago
C.
No, I stopped it MORE THAN 6 months ago
D.
No, never been on hormonal birth control
8.
Have you been diagnosed with OR are you currently experiencing any of the following?
A.
PCOS
B.
Endometriosis or Adenomyosis
C.
Uterine fibroids
D.
Ovarian Cysts
E.
PMS or PMDD
F.
Amenorrhea (no period)
G.
Estrogen dominance or low progesterone
H.
Short luteal phase
I.
None of the above
9.
Do you currently struggle with physical OR emotional PMS symptoms that disrupt your life? (Low mood, anxiety, anger, bloating, weight gain, acne, crazy cravings, breast tenderness/swelling?)
A.
Yes
B.
No
10.
Do you experience any of the following at any time during the month?
A.
Moodiness or depression
B.
Low sex drive
C.
Hair loss
D.
Headaches or migraines
E.
Energy crashes throughout the day
F.
None of the above
11.
If you're trying to lose weight, do you have trouble losing it?
A.
Yes, no matter what I do
B.
No, I can lose weight pretty easily
C.
I am not trying to lose weight
12.
When you wake up in the morning how's your energy level?
A.
I feel rested and ready to go!
B.
I feel somewhat rested
C.
I get out of bed OK but feel sluggish
D.
I feel tired ALL the time!
13.
Do you experience acne?
A.
Yes, usually when I am getting my period
B.
Very unusual. I normally don’t get acne
C.
I get acne all the time
14.
When was the last time you got your period?
A.
Less than 3 months ago
B.
3- 6 months ago
C.
More than 6 months ago
D.
I've never had a period
15.
Have you been diagnosed with any of the following?
A.
Amenorrhea
B.
PCOS
C.
Anovulation/anovulatory cycles (no ovulation)
D.
Celiac Disease
E.
None of the above
16.
On a scale of 1-5 (5 being the most stressed) what would you say your level of stress is currently?
A.
1
B.
2
C.
3
D.
4
E.
5
17.
Are you currently using hormonal contraceptives/birth control? (This includes the birth control pill, patch, IUD, implant, & Nuvaring)
A.
Yes, I am on hormonal birth control
B.
No, I stopped it LESS THAN 6 months ago
C.
No, I stopped it MORE THAN 6 months ago
D.
No, never been on hormonal birth control
18.
Do you currently struggle with physical OR emotional PMS symptoms that disrupt your life? (Low mood, anxiety, anger, bloating, weight gain, acne, crazy cravings, breast tenderness/swelling?)
A.
Yes
B.
No
19.
Do you experience any of the following at any time during the month?
A.
Moodiness or depression
B.
Low sex drive
C.
Hair loss
D.
Headaches or migraines
E.
Energy crashes throughout the day
20.
If you're trying to lose weight, do you have trouble losing it?
A.
Yes, no matter what I do
B.
No, I can lose weight pretty easily
C.
I am not trying to lose weight
21.
When you wake up in the morning how's your energy level?
