Gynaecology & General
Please provide your name, date of birth, address and email address
How old were you when you had your first period?
Sample Question 2
What was it like when it started?
What is the average time between periods now?
If they are irregular, give the shortest and longest cycles.
How long does your period last?
Which is the heaviest day(s)?
Is there any pain? How severe is it?
Describe the flow and how it changes (fresh, dark, clots, spotting, thin).
Does your mood change before your period?.
Describe the mood changes. How long before your period do they start?
Do you get any physical symptoms before your period begins?
Have you ever been pregnant? If so, do you have any children?
What were your pregnancies and labour like?
What forms of contraception have you used?
If you have been through the menopause, describe what it was like for you.
Some general questions: Do you feel more sensitive to certain temperatures or weather? Specify.
Do you get hot or sweat abnormally?
Do you have any particular problems with your ears, eyes or nose? Describe.
Describe any previous history of illness.
. Are there any hereditary diseases which run in your family? Specify which.
List all medication or supplements that you take on a regular basis.
Submit
Never submit passwords through Google Forms.
This form was created inside of Castel Complementary Medicine.