JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
WOMEN'S HEALTH SURVEY
We'd like to know more about your cycling.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
How often do you menstruate?
*
Prepuberty (not just yet)
Regular month cycles
Irregular cycles
Menopausal (stopped cycling)
I'm currently pregnant &/or nursing
Other:
The FLOW of my period is:
Light : only need a panty liner
Average : a pad/tampon every 3-4 hours
Heavy : a pad/tampon every 2 hours
Severe : I soak through clothes regularly & stay home interrupting my day
Clear selection
Symptoms I usually have with my cycles:
Bowel changes
Breast swelling
Clots
Cramping
Edema : Fluid retention/weight gain
Endometriosis
Fibroids
Food cravings
Headache
Irritable / Angry
Nausea
Pain
Sad/weepy
I am not menstruating
Other:
Clear selection
FERTILITY ISSUES
NO ISSUE
Chemical : I have been using birth control for a long time.
I'm a MOM & very busy so think it is just life stress.
I'm currently nursing my baby
I have PCOS
I have seen a fertility specialist
Other:
Check any associated symptoms you are experiencing in menopause:
Bleeding
Concentration/memory issues
Decreased Libido
Frequent Urinary Tract Infections
Headaches
Hot Flashes
Joint Pains
Mood Swings or irritability
Pain with intercourse
Palpitations
Urinary leakage
Vaginal Dryness
Weight Gain
Other:
THANK YOU!
*
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Dr Cindi Croft, PLLC.
Report Abuse
Forms
