Period Health Questionnaire

Name

First NameLast Name

Date of Birth

MonthDayYear

Email

example@example.com

Phone number

weight in kgs

Height

How old were you when your periods started?

How often do you get a period?

For the first two days of your period how heavy is the flow?

How long is your period in days?

Which PMS symptoms do you experience?

How painful are your period cramps?

Would you say your PMS and/or periods affect the quality of your life? (if yes, please give details below)

Describe a typical day of eating - breakfast lunch, dinner, snacks and drinks with times.

How many times a week do you eat the following?

Do you have any allergies? (if yes, please give details below)

Are there any foods you hate and avoid eating?

How many times a week do you drink alcohol?

How many times a week do you exercise (walking, swimming, aerobics, pilates, yoga etc)

Have you ever been to the doctor about your periods or PMS? (If yes, please give details below)

Do you suffer from any health conditions? (If yes, please give details below)

Are you on any prescription medications? (If yes, please give details below)

Do you take any supplements? (If yes, please give details below)

Is there anything else you'd like to share?