Heart_nerve Questionnaire

The fields denoted with * are compulsory fields

* Name & Surname
* Telephone
* Email
For each statement that applies to you, enter a ' X '.

1.
Do you experience premenstrual mood changes (e.g. sadness, frustration, anger, irritability) before menses?
2.
Do you have sharp, stabbing pains mid-cycle?
3.
Migraines or tension headaches often occur before menses?
4.
Are menstrual cramps characterized by sharp, stabbing pains?
5.
Medically diagnosed to have ovarian cysts?
6.
Medically diagnosed to have polycystic ovarian syndrome?
7.
Has your libido (sex drive) declined significantly?
8.
Have you experienced rapid weight loss in the past two years?
9.
Do you have episodes of heat (hot flashes)?
10.
Vaginal dryness?
11.
History of difficulties conceiving?
12.
Do not get sunshine on your skin frequently?
13.
Do not supplement with Vitamin D3, A, and K2?
14.
Do not supplement with fish/krill oil and other oils (borage, flax, cucurbito pepo, evening primrose, grape seed, etc. oils).
15.
Low abdominal pain extends to back or thighs around ovulation time.
16.
Deep aching pain, right or left low abdomen, before or during menses.
17.
Known hormonal imbalances: estrogen, progesterone, testosterone?