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1
What all are your complaints?
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PCOS DIAGNOSED
PERIODS ARE NOT ON TIME
EXCESS GROWTH OF HAIR
PIMPLES / ACNE
EXCESS VAGINAL DISCHARGE
WEIGHT ISSUES
HAIRFALL
MOOD SWINGS
Other
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2
Since when are you having these complaints?
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3
Express your complaints in your own words.
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Express the sensation or pain as it feels to you .
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4
Can you trace the origin of the present illness to any particular circumstance, mental upset, illness, incident or accident? (E.g. shock, worry, errors in diet, overexertion, overexposure to cold, heat, etc.)
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5
What are the factors that influence your trouble? e.g. weather, food, pressure, anxiety, etc. Please mention how each factor affects you, whether it increases or decreases your complaint, and also how much it affects your complaint.
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E.g. headache is worse by even little exposure to the sun, headache is better by pressing the head.
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6
Name
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First Name
Last Name
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7
Date of Birth
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Month
Day
Year
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8
E-mail
example@example.com
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9
Address:
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Street Address
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City
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Postal / Zip Code
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Tunisia
Turkey
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Other
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Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
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Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
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Uruguay
Uzbekistan
Vanuatu
Vatican City
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10
What are your Educational qualifications
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11
Occupation
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12
Weight (kgs)
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13
Height (centimetres)
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14
Phone Number
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Please enter a valid phone number.
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15
When was your FIRST PERIODS / MENSES ?
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16
When was The First day of your LAST PERIODS / MENSES ?
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Date
Year
Month
Day
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17
What’s your Marital status?
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Unmarried
Married
Separated
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18
Do you get your PERIODS on REGULAR INTERVAL ?
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YES
NO
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19
In how many days do your periods repeat?
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Within 10 days from last menses
Within 20 days from last menses
Within 28-32 days from last menses
After 40 days from last menses
After 2 or more months from last menses
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20
For how many days does your periods last ?
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1-2 days
3-4 days
5-7 days
more than 7 days
Intermittent ( Starts for few days then stop for few and then start again)
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21
Do you have clots in your periods?
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Yes
No
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22
Have you ever taken any Hormonal medicines/OC Pills/ Contraceptive pills
Yes
No
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23
Which SANITARY PRODUCT do you mostly use?
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TAMPON
SANITARY PAD
MENSTRUAL CUP
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24
Which SIZE of MENSTRUAL CUP do you mostly use?
SMALL (15-20 ML)
MEDIUM (Approx 25ML)
LARGE (Approx 35 ML)
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25
How is your bleeding on 1st day?
You collect more than 30 ml of blood in your cup every day
You collect more than 10 to 25 ml of blood in your cup every day
You collect more than 5 to 10 ml of blood in your cup every day
You collect less then 5 ml of blood in your cup every day
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26
How is your bleeding on 2nd day?
You collect more than 30 ml of blood in your cup every day
You collect more than 10 to 25 ml of blood in your cup every day
You collect more than 5 to 10 ml of blood in your cup every day
You collect less then 5 ml of blood in your cup every day
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27
How is your bleeding on 3rd day?
You collect more than 30 ml of blood in your cup every day
You collect more than 10 to 25 ml of blood in your cup every day
You collect more than 5 to 10 ml of blood in your cup every day
You collect less then 5 ml of blood in your cup every day
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28
How is your bleeding on 4th day?
You collect more than 30 ml of blood in your cup every day
You collect more than 10 to 25 ml of blood in your cup every day
You collect more than 5 to 10 ml of blood in your cup every day
You collect less then 5 ml of blood in your cup every day
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29
How is your bleeding on 5th day?
You collect more than 30 ml of blood in your cup every day
You collect more than 10 to 25 ml of blood in your cup every day
You collect more than 5 to 10 ml of blood in your cup every day
You collect less then 5 ml of blood in your cup every day
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30
How is your bleeding on 6th day?
You collect more than 30 ml of blood in your cup every day
You collect more than 10 to 25 ml of blood in your cup every day
You collect more than 5 to 10 ml of blood in your cup every day
You collect less then 5 ml of blood in your cup every day
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31
How is your bleeding on 7th day?
You collect more than 30 ml of blood in your cup every day
You collect more than 10 to 25 ml of blood in your cup every day
You collect more than 5 to 10 ml of blood in your cup every day
You collect less then 5 ml of blood in your cup every day
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32
How is your bleeding on 8th day?
You collect more than 30 ml of blood in your cup every day
You collect more than 10 to 25 ml of blood in your cup every day
You collect more than 5 to 10 ml of blood in your cup every day
You collect less then 5 ml of blood in your cup every day
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33
How is your bleeding on last day?
You collect more than 30 ml of blood in your cup every day
You collect more than 10 to 25 ml of blood in your cup every day
You collect more than 5 to 10 ml of blood in your cup every day
You collect less then 5 ml of blood in your cup every day
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34
How is your bleeding on 1st day?
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35
How is your bleeding on 2nd day?
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36
How is your bleeding on 3rd day?
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37
How is your bleeding on 4th day?
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38
How is your bleeding on 5th day?
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39
How is your bleeding on 6th day?
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40
How is your bleeding on 7th day?
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41
How is your bleeding on 8th day?
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42
How is your bleeding on Last day?
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43
How is your bleeding on 1st day?
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44
How is your bleeding on 2nd day?
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45
How is your bleeding on 3rd day?
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46
How is your bleeding on 4th day?
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47
How is your bleeding on 5th day?
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48
How is your bleeding on 6th day?
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49
How is your bleeding on 7th day?
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50
How is your bleeding on 8th day?
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51
How is your bleeding on Last day?
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52
What is the colour of your bleeding on 1st day?
*
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ORANGE
PINK
BRIGHT RED
BROWNISH
MAROON
BLACK
GREEN
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53
What is the colour of your bleeding on 2nd day?
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ORANGE
PINK
BRIGHT RED
BROWNISH
MAROON
BLACK
GREEN
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54
What is the colour of your bleeding on 3rd day?
ORANGE
PINK
BRIGHT RED
BROWNISH
MAROON
BLACK
GREEN
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55
What is the colour of your bleeding on 4th day?
ORANGE
PINK
BRIGHT RED
BROWNISH
MAROON
BLACK
GREEN
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56
What is the colour of your bleeding on 5th day?
ORANGE
PINK
BRIGHT RED
BROWNISH
MAROON
BLACK
GREEN
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57
What is the colour of your bleeding on 6th day?
ORANGE
PINK
BRIGHT RED
BROWNISH
MAROON
BLACK
GREEN
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58
What is the colour of your bleeding on 7th day?
ORANGE
PINK
BRIGHT RED
BROWNISH
MAROON
BLACK
GREEN
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59
What is the colour of your bleeding on 8th day?
ORANGE
PINK
BRIGHT RED
BROWNISH
MAROON
BLACK
GREEN
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60
What is the colour of your bleeding on Last day?
*
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ORANGE
PINK
BRIGHT RED
BROWNISH
MAROON
BLACK
GREEN
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61
What is the CHARACTER of your bleeding on 1st day?
*
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Fluid containing Clots
Containing SHREDS / MENBRANES
THIN / WATERY
FULLY CLOTTED
THICK
LUMPY
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62
What is the CHARACTER of your bleeding on 2nd day?
*
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Fluid containing Clots
Containing SHREDS / MENBRANES
THIN / WATERY
FULLY CLOTTED
THICK
LUMPY
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63
What is the CHARACTER of your bleeding on 3rd day?
Fluid containing Clots
Containing SHREDS / MENBRANES
THIN / WATERY
FULLY CLOTTED
THICK
LUMPY
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64
What is the CHARACTER of your bleeding on 4th day?
Fluid containing Clots
Containing SHREDS / MENBRANES
THIN / WATERY
FULLY CLOTTED
THICK
LUMPY
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65
What is the CHARACTER of your bleeding on 5th day?
Fluid containing Clots
Containing SHREDS / MENBRANES
THIN / WATERY
FULLY CLOTTED
THICK
LUMPY
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66
What is the CHARACTER of your bleeding on 6th day?
Fluid containing Clots
Containing SHREDS / MENBRANES
THIN / WATERY
FULLY CLOTTED
THICK
LUMPY
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67
What is the CHARACTER of your bleeding on 7th day?
Fluid containing Clots
Containing SHREDS / MENBRANES
THIN / WATERY
FULLY CLOTTED
THICK
LUMPY
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68
What is the CHARACTER of your bleeding on 8th day?
Fluid containing Clots
Containing SHREDS / MENBRANES
THIN / WATERY
FULLY CLOTTED
THICK
LUMPY
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69
What is the CHARACTER of your bleeding on Last day?
*
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Fluid containing Clots
Containing SHREDS / MENBRANES
THIN / WATERY
FULLY CLOTTED
THICK
LUMPY
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70
Does your Bleeding during Menses cause Burning?
*
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YES
NO
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71
Do you feel that your Bleeding during menses is having FOUL SMELL ?
*
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YES
NO
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72
In case, We missed anything related to your MENSES ( PERIODS), you can let us know about it here in your words!
*
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73
Do you have any white discharge/vaginal discharge?
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YES
NO
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74
Since how long are you having vaginal discharge ?
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75
How do you feel when there is a Vaginal discharge?
BURNING in & around Vagina
ITCHING in & around Vagina
NO SENSATION
Other
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76
When do you experience your VAGINAL DISCHARGE being increased?
Morning
Afternoon
Evening
Night
After prolapse of uterus
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77
When do you experience your VAGINAL DISCHARGE being increased in relation to Menses ?
Before menses
In between menses
After menses
2 weeks after menses
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78
When do you experience your VAGINAL DISCHARGE being increased?
After exercise / after motion
After pain in abdomen
During stool
During urination
After urination
After walking
After prolapse of uterus
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79
What is the type of/ texture of your VAGINAL DISCHARGE?
Albuminous / like white of the egg
BLOODY
CREAMY
JELLY LIKE
MILKY
STRINGY/ROPY
WATERY
THICK
LUMPY
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80
Do you experience constipation while having VAGINAL DISCHARGE ?
YES
NO
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81
Is it difficult to wash off the stain on your under garment?
YES
NO
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82
Do you experience any pain in abdomen while having Vaginal discharge ?
NO
YES
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83
What is the colour of your vaginal discharge ?
YELLOW
GREEN
WHITE
BROWN
RED
SKIN COLOURED
BLACK
TRANSPARENT LIKE WATER
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84
Do you get stain on your under garment when you are having VAGINAL DISCHARGE ?
YES
NO
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85
What colour of stain do you get on the inner side of the undergarment while having VAGINAL DISCHARGE?
(This staining is mostly observed after washing the UNDERGARMENT)
BROWN
YELLOW
GREEN
GRAY
COLOUR OF YOUR GARMENT FADES AWAY
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86
Do you notice any offensive/foul smell in your VAGINAL DISCHARGE?
YES
NO
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87
How do you feel is the flow in the terms of quantity of your VAGINAL DISCHARGE ?
Profuse/ Heavy / Excess in quantity
Scanty / Low in quantity
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88
Does your VAGINAL DISCHARGE causes STIFFENING/ HARDENING of the UNDERGARMENT ?
YES
NO
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89
Do you experience any of the following during VAGINAL DISCHARGE
Pain in lower back
Weakness
Anemia
Headache
VAGINAL DISCHARGE instead of menses
Palpitation
Pain in vagina
Swelling of vagina
Pain in urination
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90
In case We missed anything related to your VAGINAL DISCHARGE, you can let us know about it here in your words!
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