Your Energy Levels: Good Low/Mornings Low/Evenings Low/All Day

Sweating: on slight exertion at night or is it normal

Temperature of your Hands or Feet: normal always cold always hot

Appetite: normal /  Has is changed recently to: poor excessive

Abdominal pain: Nausea Vomiting Bloating Belching Gas

Do you crave any particular taste? none metalic sour spicy salty pungent sweet

Are you thirsty? normal excessive thirst only sip my water

How much do you drink per day: 1 litre per day 2 litres per day 3 litres per day 4 litres per day more than 4 litres per day

Stools: are they normal hard or constipation loose or diarrhoea

Urination: is it normal scanty profuse        /   Is it frequent      / Does it burn

Do you experience -  Incomplete urination: Dribbling: Wake at night to go:

Sleep: Good: Difficulty Falling Asleep Difficulty Staying Asleep/Restless

Sleep: Excessive Dreams: Nightmares: What time do you regularly wake: 1 am 2 am 3 am 4 am 5 am 6 am 7 am 8 am  

Do you experience any excessive emotions: normal anger fear worry sadness

How many days in your:  Menstrual cycle: None 20 to 25 days 25 to 28 days 28 to 30 days 30 to 35 days 35 to 40 days   / Flow: 1 day 2 days 2 to 3 days 4 to 5 days 5 to 6 days 6 to 8 days 8 to 10 days 10 to 15 days constant spotting None

Is your period regular irregular

Any headaches associated with period/where

Painful periods No Pain Before  Pain During  Pain After  Pain throughout period

Describe the location of the pain

Describe the Pain: No Pain Pain - discomfort, no effect on work Intense pain - sometimes need pain killers to continue work Sever pain - can not work, vomiting, nausea, sweating

Clots:

Do you bleed: normal very little excessive varying amounts

Have given birth: never 1to3 children 3 to 6 children more than 6 children