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Birthday
Month
Day
Year
I have a hard time falling asleep:
never
rarely
sometimes
frequently
always
I wake up often:
never
rarely
sometimes
frequently
always
I wake up rested:
never
rarely
sometimes
frequently
always
I am aways cold:
never
rarely
sometimes
frequently
always
My hair is falling out:
never
rarely
sometimes
frequently
always
I am tired all the time:
never
rarely
sometimes
frequently
always
I am often stressed:
never
rarely
sometimes
frequently
always
Mood swings are intense each month:
never
rarely
sometimes
frequently
always
I have headaches:
never
rarely
sometimes
frequently
always
I battle anxiety:
never
rarely
sometimes
frequently
always
I battle depression:
never
rarely
sometimes
frequently
always
I have a hard time losing weight:
never
rarely
sometimes
frequently
always
I struggle with body or facial hair:
not at all
some
its bad
I have acne:
not at all
some
its bad
My cycle is regular:
shorter
26-32 days
longer
I have PMS cramping:
none
mild
moderate
severe
I have experienced pregnancy loss:
yes
no
I am trying to conceive:
yes
no
I am currently pregnant:
yes
no
I am currently breastfeeding:
yes
no
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