PMDD Scale

Premenstrual Dysphoric Disorder (PMDD) Scale

Please answer as honestly as you can.
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Patient Name:*

First NameLast Name
Date Of Birth:*

MonthDayYear
Date
Email*
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Instructions:

1.) Begin tracking your premenstrual symptoms with this chart today. Fill it out daily
(preferably at the end of your day). Two full months of menstrual cycle charting will allow for a more accurate assessment. A full menstrual cycle (28 – 40 days) of charting will allow for a more accurate assessment.

2.) Each evening note the degree to which you experienced each of the problems listed below. Mark the box in the box which corresponds to the severity:

TIP: Every day, rate what you have experienced under ALL of the column headings. Do not look at your ratings from the previous day, (covering previous ratings with another piece of paper is helpful) so that you rate each day individually – do not rate your day’s experience compared to yesterday or previous days.

Rating Scale:

1 - Not At All | 2 - Minimal | 3 - Mild | 4 - Moderate | 5 - Severe | 6 - Extreme
FIRST MONTH:

(Example: Answer to #1 - (3) (2) (4) (5) (4) (6) - Monday the 3rd) *

	Not At All (1)	Minimal (2)	Mild (3)	Moderate (4)	Severe (5)	Extreme (6)	Day Of The Week	Date Of The Month
1.) Felt depressed, sad, “down,”, or “blue” or felt hopeless; or felt worthless or guilty
2.) Felt anxious, tense, “keyed up” or “on edge”
3.) Had mood swings (i.e., suddenly feeling sad or tearful) or was sensitive to rejection or feelings were easily hurt
4.) Felt angry, or irritable
5.) Had less interest in usual activities (work, school, friends, hobbies)
6.) Had difficulty concentrating
7.) Felt lethargic, tired, or fatigued; or had lack of energy
8.) Had increased appetite or overate; or had cravings for specific foods
9.) Slept more, took naps, found it hard to get up when intended; or had trouble getting to sleep or staying asleep
10.) Felt overwhelmed or unable to cope; or felt out of control
11.) Had breast tenderness, breast swelling, bloated sensation, weight gain, headache, joint or muscle pain, or other physical symptoms
12.) At work, school, home, or in daily routine, at least one of the problems noted above caused reduction of production of efficiency
13.) At least one of the problems noted above caused avoidance of or less participation in hobbies or social activities
14.) At least one of the problems noted above interfered with relationships with others

(Example: Answer to #1 - (3) (2) (4) (3) (4) (4) - Monday the 3rd) *

	Not At All (1)	Minimal (2)	Mild (3)	Moderate (4)	Severe (5)	Extreme (6)	Day Of The Week	Date Of The Month
1.) Felt depressed, sad, “down,”, or “blue” or felt hopeless; or felt worthless or guilty
2.) Felt anxious, tense, “keyed up” or “on edge”
3.) Had mood swings (i.e., suddenly feeling sad or tearful) or was sensitive to rejection or feelings were easily hurt
4.) Felt angry, or irritable
5.) Had less interest in usual activities (work, school, friends, hobbies)
6.) Had difficulty concentrating
7.) Felt lethargic, tired, or fatigued; or had lack of energy
8.) Had increased appetite or overate; or had cravings for specific foods
9.) Slept more, took naps, found it hard to get up when intended; or had trouble getting to sleep or staying asleep
10.) Felt overwhelmed or unable to cope; or felt out of control
11.) Had breast tenderness, breast swelling, bloated sensation, weight gain, headache, joint or muscle pain, or other physical symptoms
12.) At work, school, home, or in daily routine, at least one of the problems noted above caused reduction of production of efficiency
13.) At least one of the problems noted above caused avoidance of or less participation in hobbies or social activities
14.) At least one of the problems noted above interfered with relationships with others

Reference: file:///Users/amandaamblo/Downloads/2021%20UPDATED%20Symptom%20%20tracker%20(1).pdf
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Premenstrual Dysphoric Disorder (PMDD) Scale