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