undefined

Menstrual Irregularities Questionnaire

Uncover the root cause of your menstrual irregularities with our comprehensive questionnaire. From missed periods to heavy bleeding, our detailed assessment will help you pinpoint potential issues and guide you towards the right treatment. Take control of your reproductive health today and get the answers you need. Start the journey towards a healthier menstrual cycle with our Menstrual Irregularities Questionnaire.

3 minutes to complete

Questions for Menstrual Irregularities Questionnaire

Questions

1.

Age:

The answer should be a single choice:
  1. Under 18
  2. 18-24
  3. 25-34
  4. 35-44
  5. 45-54
  6. 55 and older
2.

Menstrual Cycle Start Age:

The answer should be a single choice:
  1. Under 10
  2. 10-12
  3. 13-15
  4. 16 or older
3.

How regular are your menstrual cycles?

The answer should be a single choice:
  1. Very regular (every 21-35 days)
  2. Somewhat regular (irregular but predictable)
  3. Very irregular (no predictable pattern)
  4. I do not have menstrual cycles
4.

What is the typical duration of your menstrual periods?

The answer should be a single choice:
  1. Less than 2 days
  2. 2-3 days
  3. 4-5 days
  4. More than 5 days
5.

Do you experience any of the following symptoms during your period? (Select all that apply)

The answer should be a multiple choice:
  1. Abdominal cramps
  2. Headaches or migraines
  3. Mood swings or irritability
  4. Fatigue or low energy
  5. Nausea or vomiting
6.

On a scale of 1 to 10, how would you rate the severity of your menstrual pain?

The answer should be a rating.
7.

Do your menstrual symptoms affect your daily activities?

The answer should be a single choice:
  1. Not at all
  2. A little bit
  3. Moderately
  4. Very much
8.

Have you ever missed work or school due to menstrual symptoms?

The answer should be a single choice:
  1. Yes, frequently
  2. Yes, occasionally
  3. No, never
9.

Are you currently taking any medication that affects your menstrual cycle?

The answer should be a single choice:
  1. No
10.

Have you experienced any significant changes in your menstrual cycle in the past year?

The answer should be a single choice:
  1. No
11.

Do you have any additional comments or concerns regarding your menstrual health?

The answer should be a text input.

Questionnaires Similar to Menstrual Irregularities Questionnaire

  • Menstrual Health Assessment Questionnaire
  • Menstrual Symptom Survey
  • Menstrual Cycle Evaluation Form
  • Menstrual Health History Questionnaire
  • Menstrual Cycle Tracking Questionnaire
  • Menstrual Health Questionnaire

Here are some FAQs and additional information
on
Menstrual Irregularities Questionnaire

What is a Menstrual Irregularities Questionnaire?

A Menstrual Irregularities Questionnaire is a tool used by healthcare providers to gather information about a person's menstrual cycle patterns, symptoms, and overall reproductive health.

Why is it important to fill out a Menstrual Irregularities Questionnaire?

Filling out a Menstrual Irregularities Questionnaire can help healthcare providers understand any underlying issues causing irregularities in a person's menstrual cycle and develop an appropriate treatment plan.

Who should fill out a Menstrual Irregularities Questionnaire?

Anyone experiencing irregularities in their menstrual cycle, such as changes in frequency, duration, or intensity of periods, should fill out a Menstrual Irregularities Questionnaire.

Can a Menstrual Irregularities Questionnaire diagnose a medical condition?

A Menstrual Irregularities Questionnaire is a tool used to gather information and is not a diagnostic tool. It can help healthcare providers identify patterns and potential causes of menstrual irregularities.

Want to use this template?

Testimonials

G2 BadgesG2 BadgesG2 BadgesG2 BadgesG2 Badges

What's next? Try out templates like
Menstrual Irregularities Questionnaire

1000+ Templates, 50+ Categories

Want to create secure online forms and surveys?

Join BlockSurvey.

About Us

BlockSurvey is a privacy-focused platform for collecting data through forms, surveys, assessments, and quizzes. The data collection is end-to-end encrypted, and it ensures complete privacy of your audience from Big Tech. With an array of ready to use templates, it is tailored for the needs of businesses and individuals from Web 3, HR, Mental Health, Sexual Health, Activism and many sensitive areas where data collection needs protection.

SHARE