Last Period Date:

Cycle Length (days):

Notify me before next period:

1. How old were you when you got your first period?

Under 12
12-14
Over 14

2. How often do you experience irregular periods?

Rarely
Sometimes
Frequently

3. Have you ever been diagnosed with any menstrual disorders (e.g., PCOS)?

Yes
No

4. How do you manage period pain?

Painkillers
Heat Therapy
Exercise
Diet Changes

5. Do you track your menstrual cycle regularly?

Yes
No

1. Do you often feel low during your period?

Yes
No

2. How frequently do you experience mood swings?

Rarely
Occasionally
Often

3. What activities help you improve your mood?

Exercise
Reading
Listening to Music
Socializing
Meditation

4. Do you find it helpful to talk about your mood with someone?

Yes
No