If you would like to share your experience of menstrual pain, please take a few minutes to fill in this form.
Age I got my period:
Age I first experienced menstrual pain:
I have the following medical problems related to my menstrual pain:
I use birth control pills: Yes No
I have an IUD: Yes No
Where I get pain during my period (check all that apply): Headache Lower Abdomen Back Thighs Breasts Other
The following best describes my period pain: Constant dull pain/pressure Pain coming in waves every minutes Other
Three or more days before my period starts my pain is: Negligable Mild Moderate Severe Incapacitating Comments/Other:
Two days before my period starts my pain is: Negligable Mild Moderate Severe Incapacitating Comments/Other:
One day before my period starts my pain is: Negligable Mild Moderate Severe Incapacitating Comments/Other:
The day my period starts my pain is: Negligable Mild Moderate Severe Incapacitating Comments/Other:
On day 2 of my period my pain is: Negligable Mild Moderate Severe Incapacitating Comments/Other:
On day 3 of my period my pain is: Negligable Mild Moderate Severe Incapacitating Comments/Other:
On day 4 of my period my pain is: Negligable Mild Moderate Severe Incapacitating Comments/Other:
On day 5 of my period my pain is: Negligable Mild Moderate Severe Incapacitating Comments/Other:
On day 6 of my period my pain is: Negligable Mild Moderate Severe Incapacitating Comments/Other:
On day 7 of my period my pain is: Negligable Mild Moderate Severe Incapacitating Comments/Other:
Check any that apply: I sometimes miss work or school because of period pain Comments:
I sometimes canceldates or miss social events because of period pain Comments:
I sometimes skip sports or exercise because of period pain Comments:
I sometimes avoid sex because of period pain Comments:
I sometimes avoid because of period pain
Things I've tried to make my period pain better:
Walking never tried helps makes it worse no effect Comment:
More vigorous exercise (situps, jogging, swimming, etc) never tried helps makes it worse no effect Comment:
Bed rest, sleeping never tried helps makes it worse no effect Comment:
Heat never tried helps makes it worse no effect Comment:
Orgasm never tried helps makes it worse no effect Comment:
Dietary changes never tried helps makes it worse no effect Comment/details:
Meditation, Yoga, etc. never tried helps makes it worse no effect Comment:
Acupuncture/Acupressure never tried helps makes it worse no effect Comment:
Over the counter medications never tried helps makes it worse no effect Comment/details:
Prescription medications never tried helps makes it worse no effect Comment:
Other things that I have found helpful:
Things that I have found make my pain start or get worse:
Activities that I avoid during menstruation whether or not I am having pain:
Relatives that also suffer from period pain (mother, sisters, cousins, etc.)
Finally, it would be helpful if you would describe the pain you get with a typical period. Please include information about the timing and severity of the pain.
Thank you for taking the time to fill out this long questionaire.