Carefree Periods template

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Question 1 of 12

1. Question
1. How many days do you bleed heavily?
- 1 = Not at All
- 2= 1 day
- 3= 2-3 days
- 4= 4-8 days
- 5= more than 8 days
Question 2 of 12

2. Question
2. How many days do you experience excessive pain?
- 1 = Not at All
- 2= 1 day
- 3= 2-3 days
- 4= 4-8 days
- 5= more than 8 days
Question 3 of 12

3. Question
3. How many days do you take pain medication?
- 1 = Not at All
- 2= 1 day
- 3= 2-3 days
- 4= 4-8 days
- 5= more than 8 days
Question 4 of 12

4. Question
4. How many days do you feel bloated / uncomfortable?
- 1 = Not at All
- 2= 1 day
- 3= 2-3 days
- 4= 4-8 days
- 5= more than 8 days
Question 5 of 12

5. Question
5. How many days are you absent and/or are less productive?
- 1 = Not at All
- 2= 1 day
- 3= 2-3 days
- 4= 4-8 days
- 5= more than 8 days
Question 6 of 12

6. Question
6. Do you feel insecure that time of the month?
- 1 = Not at All
- 2= a little
- 3= moderately
- 4= Mostly
- 5= completely
Question 7 of 12

7. Question
7. Do you plan your activities around your periods?
- 1 = Not at All
- 2= a little
- 3= moderately
- 4= Mostly
- 5= completely
Question 8 of 12

8. Question
8. Are you emotional, irrational and/or fight with others that time of the month?
- 1 = Not at All
- 2= a little
- 3= moderately
- 4= Mostly
- 5= completely
Question 9 of 12

9. Question
9. How much are your periods negatively impacting your quality of life?
- 1 = Not at All
- 2= a little
- 3= moderately
- 4= Mostly
- 5= completely
Question 10 of 12

10. Question
10. Ovarian Cysts

Have you been diagnosed with ovarian cysts?
If yes, what is the size of the biggest one at this point in time?

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- This response will be reviewed and graded after submission.
Question 11 of 12

11. Question
11: How many years have you been struggling
1. How old where you when your menstrual cycles started?
2. How old were you when the problems with your cycle started?
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Question 12 of 12

12. Question
12. The comparison between now and before you started

Now that you have completed this quiz, please compare these answers with your starting point.

Write down what you have observed.

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Quiz Summary

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1. Question

1. How many days do you bleed heavily?

2. Question

2. How many days do you experience excessive pain?

3. Question

3. How many days do you take pain medication?

4. Question

4. How many days do you feel bloated / uncomfortable?

5. Question

5. How many days are you absent and/or are less productive?

6. Question

6. Do you feel insecure that time of the month?

7. Question

7. Do you plan your activities around your periods?

8. Question

8. Are you emotional, irrational and/or fight with others that time of the month?

9. Question

9. How much are your periods negatively impacting your quality of life?

10. Question

10. Ovarian Cysts

Ignore that this question will be graded

11. Question

11: How many years have you been struggling

Ignore that this question will be graded

12. Question

12. The comparison between now and before you started

(Ignore that this question is being graded)