Enrollment: Premenstrual Disorders Study

Please fill in the form as best you can – if unsure about any question just leave blank. 

Confidentiality is assured.

Ts&Cs

12 + 2 =

Symptom List
(not exhaustive)
If you have any of these, please list them on the form and rate the intensity of each on a scale of 1 (least intense) to 10 (most intense).
Add any others you may have.

Pre-menstrual

Cramping
Appetite changes
Food cravings
Swollen or tender breasts
Constipation / Diarrhea
Bloating / Gas
Headache
Backache
Clumsiness
Sensitivity to light or noise
Irritability
Anxiety
Depression / Sadness/ Crying
Mood swings
Lower libido
Tiredness
Changes in sleep patterns
Problems concentrating
Memory

During the flow

Cramping or other pain
Clots
Too much blood
Too little blood
Headache
Ovarian pain
Very Pale or Very Dark blood
Constipation / Diarrhea

Other times

Ovarian pain
Discharge
Spotting / Blood flow

And anything else you may have