Varafem Menstrual Cycle Symptom Assessment

Here's What to Expect Varafem is designed to give you more control over your menstrual cycle symptoms. Our team of medical experts gather information, perform an assessment and design custom remedies that actually work so you can live life uninterrupted. To get started, all you have to do is answer a few questions.

Personal Info* This field is required.

First Name

Last Name

Please enter your email

Please enter your phone number

Address

City

State

Zip code

What's your date of birth* This field is required.

Date

Gender* This field is required.(Please select your physiological gender)

Female

Male

Other

How do you know when you're about to start your period?* This field is required.(Select all that apply)

I feel pain a few days before it starts

I experience symptoms OTHER THAN pain a few days before it starts

I have a period tracker that tells me when I'm about to start

Other

Which period tracker do you use?

Please tell us more about your pain by selecting all that apply to you around the time of your period?Select all that apply

Pubic / Pelvic pain

Lower back pain

Thigh Pain

Cramping

Abdominal pain and soreness

Joint pain and soreness

Muscle pain and soreness

Other

How many days before your period do you start feeling pain?

More then 3 days before

3 days before

2 days before

1 day before

On the day flow starts

Other

What would you rate your pain on its worst day?Each face represents the intensity of pain. a complete frown represents the worse pain imaginable and a complete smile represents no pain at all

Please tell us more about your OTHER symptoms. Which of these symptoms do you experience?(Select all that apply)

Acne

Headache

Weight gain

Lack of concentration

Insomnia

Sore Breast

Water retention / bloating

Constipation

Diarrhea

Nausea

Passing excessive amounts of gas

Loss of appetite

Food cravings

Fatigue

Insomnia (Trouble Sleeping)

Depression

General discontent

Mood swings

Irritability

Anxiety

Abdominal/Pelvic fullness

Other

How many days before your period do you start experiencing symptoms other than pain?

More then 3 days before

3 days before

2 days before

1 day before

On the day flow starts

After your period starts do you?Select all that apply

Feel pain

Experience symptoms other than pain

Feel fine and have no symptoms

Other

How long after flow starts does your pain last?

1 day After

2 days After

3 days After

4 days After

5 + days After

I don't have any pain after my period starts

Please tell us more about your OTHER symptoms. Which of these symptoms do you experience AFTER your period starts?(Select all that apply)

Acne

Headache

Weight gain

Lack of concentration

Insomnia

Sore Breast

Water retention / bloating

Constipation

Diarrhea

Nausea

Passing excessive amounts of gas

Loss of appetite

Food cravings

Fatigue

Insomnia (Trouble Sleeping)

Depression

General discontent

Mood swings

Irritability

Anxiety

Abdominal/Pelvic fullness

Other

How long after flow starts do you experience other symptoms?

1 day after

2 days after

3 days after

4 days after

More then 4 days after

None

Which remedies do you use to deal with your symptoms?(Select all that apply)

I take medications as soon as I think its about to start

I lay in bed avoiding everybody and everything and try to wait it out

I use a heating pad, warm bath, cup of tea and lots of TLC

I live my life like nothing's wrong and "just deal with it"

Other

What symptoms aren't addressed that you wish were addressed by your current remedies?

Acne

Headache

Weight Gain

Lack of concentration

Insomnia

Sore Breasts

Water retention or bloating

Constipation

Diarrhea

Nausea

Passing of excessive amounts of gas

Loss of appetite

Food cravings (get in my belly)

Fatigue

Insomnia (Trouble sleeping)

Depression

Irritability (Mad at...yea just don't)

Mood swings

Anxiety

Pelvic pain

Lower back pain

Thigh pain

Cramping

Abdominal pain

Soreness

Joint pain & soreness

Muscle pain & soreness

Other

Which medications do you take?* This field is required.(Select all that apply)

Midol

Acetaminophen (Tylenol)

Pamprin

Excedrin (Caffeine, Acetaminophen, Aspirin)

Ibuprofen (Advil)

I take prescription medications

Other

What is the name and strength of the medication you take?

Use the emoji slider to indicate how effective this medication is in treating your pain

What other symptoms does this medication address?(Select all that apply)

Acne

Headache

Weight Gain

Lack of concentration

Insomnia (Can't sleep)

Sore Breasts

Water retention or bloating

Constipation

Diarrhea

Nausea

Passing of excessive amounts of gas

Loss of Appetite

Food Cravings (Get in my belly)

Fatigue

Insomnia (Trouble sleeping)

Depression

Irritability (Mad at... yea just don't)

Mood Swings

Anxiety

Pelvic Pain

Lower Back Pain

Thigh Pain

Cramping

Abdominal pain

Soreness

Joint pain & soreness

Muscle pain & soreness

Other

Use the emoji slider to indicate how effective the medication you're currently taking is in treating your other symptoms?

What don't you like about this medication

How have the symptoms of your menstrual cycle affected your life?Select all that apply

It causes me to miss work and/ or school

It causes me to withdraw from social interaction

I get less done when I'm on my period

Life goes on so I don;t let my symptoms bother me

Interferes with physical activity

Other

Which of these apply to you?

I'm pregnant

I smoke cigarettes

Sometimes I drink alcohol

I take medications, vitamins and/or supplements Not yet mentioned in this assessment

I've been diagnosed with a health condition

I'm breast feeding

None of these options apply to me

What medical conditions have you been diagnosed with?* This field is required.

Are you allergic to any medications or any other substances such as food, environmental and ect ?* This field is required.

YESNO

What are you allergic to?

How many days total do you experience pain around the time of your period?Use the slider to indicate how many days the pain usually lasts from the first to the last day you feel pain

How many days total do your symptoms OTHER than pain last?Use the slider to indicate how many days the your other symptoms usually last. (Pick the symptom that lasts the longest to indicate the total duration)

What prescription or over the counter medications or supplements do you take?Don't forget to include the strength of the medication and how often you take it.

How many packs of cigarettes do you smoke per day?

1 pack

2 packs

3 packs

4 packs

More than 4 packs

How often do you drink?

Every day

Often 4-6 days per week

Sometimes ( 1-3 times per week)

Occasionally (on special occasions) < 4 times per month

What types of remedies do you prefer when treating the symptoms of your period?* This field is required.Select all that apply

Natural

Pharmaceutical

I don't care...whatever works

I'll pass on the pills

Are you ready to get rid of these symptoms?If you're ready to purchase your kit click "YES" to subscribe. If you just want to submit your results click "NO" to submit your assessment.

YESNO

Which option works best for you?

Please make this as easy as possible and have a doctor evaluate my symptoms for just $20

I'll have my symptoms evaluated by my doctor but still want a Varafem Relief Remedy

Do we have your permission to contact your doctor and discuss the results of this assessment with them?If you select "No" then you will be responsible for asking your doctor to contact us so we can provide the results of your assessment.

YESNO

Please provide your doctor's contact information.We may contact your Doctor and forward

Doctor's First Name

Doctor's Last Name

Doctor's Phone Number

My SubscriptionWe will create a custom kit that has everything you need to provide relief from your menstrual cycle symptoms. The items in your kit will be designed and selected specifically for you based upon the information we've collected and the doctor's recommendation. Once your kit is designed a pharmacist will contact you to review each item in the kit, explain how to use each medication and answer every question that you may have. Select an option that fits your needs

Varafem Relief Package
$59.00 for each month
SUBSCRIBE

Since you've asked us to have a doctor evaluate your symptoms we've brought you to their front desk. Here, you can pay for the assessment and sign patient intake documentation .