PMS & ME

Little Bit About You

Name

Email Address

Age

How is Your Mood?

How does your cycle affect your mood?

No changes.

Small changes.

Noticeable changes.

Big changes.

Do you feel anxious, sad or low energy around your period?

Never.

Sometimes, but it's mild.

Often, and it's noticeable.

Very often, and it's intense.

Does your confidence or motivation change?

No, I feel steady all month.

Occasionally, but it's not a big deal.

Often, and it affects my energy.

Very often, and it disrupts my goals.

How Does Your Body Feel?

How is Your Sleep?

Do you have trouble falling asleep or you feel overly tired?

No, I sleep well all the time.

Rarely, and it's not a big issue.

Yes, and it disrupts my rest.

Very often - it really affects how I sleep.

How is Your Day Affected?

Does your cycle affect your work, school, or social life?

Not at all.

A little, but I handle it easily.

Sometimes, I need to adjust.

Often, it disrupts my day.

How Do You Care for Yourself?

Do you use rest, exercise, or medication to handle your symptoms?

Never - I don't need to.

Rarely, just for mild discomfort.

Often, and they help a lot.

Very often - I can't function without them.

Have you ever sought professional help?

No, I've never needed it.

No, but I've thought about it.

Yes, and it helped a bit.

Yes, and it's been essential.

How Do You Handle PMS?