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Height
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Weight (lbs)
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Married
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Single
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# of children
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Level of overall health (1-10)
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Current prescription meds
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Vitamins & herbal supplements
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How often do you exercise?
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Here for what health issue?
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Treatments tried before
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What is diagnosis by MD?
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How long have you had this condi
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How long are your menstrual cycl
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How long does your period flow?
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Do you have mentsrual cramps?
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Are there clots in your menses?
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Do you have headaches during your period.
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Do you have sore breasts.
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