Client Information
PMDD Questionnaire
1. Pronouns
2. Gender Identification
3. Gender Assigned at Birth
4. Sexual Orientation
5. Have you ever recorded daily ratings of your PMDD symptoms (paper & pencil, PreMentricS app, etc.)? If so, for how long?
6. Have you been diagnosed with migraines?
7. If you get migraines, do they become worse or more likely to happen around menstrual onset?
8. Do you have any gynecologic disorders, like PCOS, adenomyosis, or endometriosis?
9. Do you have any OTHER current OR PAST physical health diagnoses (e.g., diabetes, stroke, cancer, autoimmune diseases, asthma, etc)?
10. Do you believe you have any ongoing mental health symptoms other than PMDD (e.g., chronic depression, anxiety, schizophrenia, panic disorder, etc)? Please note that this does not mean you can't also have a cyclical mood disorder, like PMDD.
11. Do you have biological children that you gave birth to? If so, how old are they?
12. If yes, did you experience any mood changes (either positive or negative) during pregnancy?
13. Do you experience dysmenorrhea symptoms? (Intense pain that requires work or school absence, fever, fainting, sweating, shakiness, diarrhea during menses)
14. Are you experiencing any of the following: hot flashes? Night sweats? Vaginal dryness? Painful intercourse? Unpredictable or more varying cycle lengths?
15. What was the age of your first menstrual period?
16. How many days is your typical menstrual cycle? (hint: average is 28 days)
17. Have you ever taken selective serotonin reuptake inhibitors for PMDD? If so, which ones? Did you take them the whole month, or only in the luteal phase?
No Fluoxetine (Prozac) - note how you responded Sertraline (Zoloft) - note how you responded Other Antidepressant - note which ones and how you responded
Briefly state what your symptoms were like on this medication.
18. Have you ever taken birth control pills for PMDD? Did you take them continuously, or with breaks?
No Continuously with no inactive pills (note how you responded) 24 active pills and 4 inactive pills (note how you responded) 21 active pills and 7 inactive pills (note how you responded) I've never taken BC or I only took it before my PMDD started
Briefly state what your symptoms were like on this medication.
19. Have you ever specifically taken any of the following Birth Control Pills specifically?
No Yaz Yazmin Ocella Nikki
Briefly state what your symptoms were like on this medication.
20. Have you used a copper IUD?
21. Have you ever taken any other form of hormones? This includes: IUD with hormones, patch with hormones, implant with hormones, vaginal ring with hormones, or hormone replacement therapy
22. Have you ever been prescribed a GnRH agonist therapy (e.g., Lupron injections) for PMDD or another disorder? If so, were you prescribed addback estrogen or progesterone? Briefly describe your experience.
23. What medications are you CURRENTLY taking or using? Please include dosages for medications
