Menstrual Cycle Quiz

Menstrual Cycle Quiz

Your journey to menstrual cycle healing starts here. Feel free to provide as detailed information as possible to allow for comprehensive assessment of your menstrual problems.
Name*

First NameLast Name
E-Mail*
Birth Date*

DayMonthYear
Gender*
Weight (kg's)
Do you have a menstrual cycle?

YesNo
What was your experience of your first bleed (menarche) like? *
Were you sufficiently supported, and informed? Please share your experience*
Was it celebrated in any way? Were there any stressful circumstances going on around you?*
Describe your current experience of your menstrual cycle including feelings, energy levels, and any physical symptoms. *
Have you ever used hormonal contraception? (e.g. the Pill, Mirena or copper coil, patches, injections, or implants) And if so when and for how long?*
What is important to you? What do you most love doing? How much are you able to follow what you really love to do?*
Is there anything else that you think it would be helpful for me to know about you? Any life challenges present or past? (You don’t have to share anything here, only if you feel it would be helpful to understanding your current situation)*
What is your intention or aim for this session. What do you hope to get out of it?*
If you didn’t have to worry about the rest of the world, what would you most love to be doing leading into and during menstruation ?*
Please list any allergies
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderFainting SpellsGallstonesHeart DiseaseHigh Blood PressureDigestive ProblemsThyroid ProblemsNeurological DisordersBleeding Disorders
Other illnesses:
Please list your Current Medications
Exercise

Never1-2 days3-4 days5+ days
Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Menstrual cycle*
Should be Empty: