WOMAN’S BALANCE

PMS Baseline Questionnaire

Every woman experiences PMS differently. This questionnaire helps us understand your individual symptoms, their severity, and how they affect your everyday life before you begin using Woman’s Balance.

There are no “right” or “wrong” answers. Please answer based on what you typically experience during the days leading up to your period.

Woman’s Balance is not intended for use during pregnancy.

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01 About You

Age

18–2425–2930–3435–3940–4445+

Height

Weight

02 Your Menstrual Cycle

Are your periods usually regular?

YesMostly regularIrregularVery irregular

Approximately how long is your usual menstrual cycle?

Less than 21 days21–24 days25–28 days29–32 days33–35 daysMore than 35 daysIt varies / I’m not sure

How many days does your period usually last?

1–2 days3–4 days5–6 days7+ days

When did your most recent period begin?

How would you describe your usual menstrual flow?

LightModerateHeavyVery heavyIt varies

Do you commonly have menstrual cramps or pelvic pain?

NoMildModerateSevereExtremely severe

At its worst, how would you rate your menstrual pain?

0 — No pain10 — Worst imaginable pain

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03 Tell Us What PMS Feels Like for You

During the days before your period, which symptoms do you typically experience? Select all that apply.

Physical Symptoms

Cramps / pelvic painLower-back painHeadacheMigraineBloatingWater retention / swellingBreast tendernessGeneral body achesFeeling physically heavy or uncomfortableAcne / skin changesNauseaDigestive changesConstipationDiarrheaIncreased sensitivity to pain

Other

Mood & Emotional Symptoms

IrritabilityAnger / short temperMood swingsAnxiety / nervousnessFeeling tense or on edgeSadnessFeeling like cryingFeeling overwhelmedFeeling unusually emotionalFeeling more sensitive to criticism or conflictWanting to be aloneLoss of interest in usual activitiesFeeling like “I’m not myself”

Other

Energy & Mental Symptoms

FatigueLow energyLow motivationBrain fogDifficulty concentratingForgetfulnessDifficulty making decisionsDaytime sleepinessFeeling mentally exhausted

Other

Sleep

Difficulty falling asleepWaking during the nightRestless sleepWaking too earlySleeping more than usualWaking up tiredSleep becomes noticeably worse before my period

Other

Appetite & Cravings

Increased appetiteSweet cravingsChocolate cravingsSalty-food cravingsCarbohydrate cravingsBinge eating / difficulty controlling eatingDecreased appetite

Other

04 How Severe Are Your PMS Symptoms?

Rate how severe each symptom typically becomes at its worst. 0 = Not present. 10 = Extremely severe.

You did not select any symptoms. You may continue or go back to add them.

05 When Does PMS Start for You?

How many days before your period do you usually begin noticing PMS symptoms?

1–2 days3–4 days5–7 days8–10 daysMore than 10 daysIt varies

When do you usually begin feeling like yourself again?

When my period beginsDuring the first 1–2 days of my periodToward the end of my periodAfter my period endsIt varies

06 How PMS Affects Your Life

How much does PMS interfere with your normal daily life?

0 — Not at all10 — Extremely

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During PMS, does it negatively affect any of the following?

Work or schoolProductivityExercise / physical activityHousehold responsibilitiesSocial activitiesRelationship with my partnerRelationship with my children/familyFriendshipsDesire to communicate with peopleIntimacy / sex lifeMy confidenceMy overall quality of lifeNone of these

Have PMS symptoms ever caused you to miss work, school, social events, exercise, or other planned activities?

NeverRarelySometimesOftenAlmost every cycle

During PMS, how often do you feel like you are “not yourself”?

NeverRarelySometimesOftenAlmost every cycle

07 Mood & Emotional Well-Being

Irritability

010

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Anxiety / tension

010

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Mood swings

010

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Sadness / low mood

010

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Feeling overwhelmed

010

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Emotional sensitivity

010

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08 Energy & Mental Clarity

Fatigue

010

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Brain fog

010

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Difficulty concentrating

010

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Low motivation

010

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How would you rate your overall energy during PMS?

0 — No energy at all10 — Excellent energy

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09 Sleep

Approximately how many hours do you usually sleep per night?

Less than 55–66–77–8More than 8

Does your sleep become worse before your period?

Yes, significantlyYes, somewhatNo noticeable differenceI’m not sure

How rested do you usually feel when you wake up during PMS?

0 — Completely exhausted10 — Fully rested

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10 Appetite & Cravings

Do your appetite or food cravings noticeably change before your period?

Yes, significantlyYes, somewhatNoNot sure

How difficult are your cravings to control?

0 — No problem10 — Extremely difficult

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11 Digestion & Bloating

During PMS, do you experience:

BloatingConstipationDiarrheaGasAbdominal discomfortChanges in bowel habitsNone of these

How severe is your bloating at its worst?

0 — None10 — Extremely severe

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12 Urinary & Bladder Symptoms

Around the days before or during your period, do you experience any of the following? Select all that apply.

Needing to urinate more frequently than usualSudden or urgent need to urinateBurning or stinging when urinatingBladder pressure or discomfortLower abdominal / pelvic discomfort associated with urinationFeeling that your bladder has not completely emptiedWaking at night to urinate more often than usualSymptoms that feel similar to a urinary tract infection (UTI)None of these

Other

If you experience these symptoms, when do they usually appear?

7–10 days before my period3–6 days before1–2 days beforeDuring my periodAfter my periodAt several points during my cycleNo clear pattern

How severe do these symptoms become at their worst?

0 — None10 — Extremely severe

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Do these symptoms tend to improve or disappear after your period ends?

Yes, usuallySometimesNoNot sure

Have you ever been tested for a UTI when these symptoms occurred?

Yes — test was positiveYes — test was negativeYes — results have variedNoI don't remember

13 Stress & Lifestyle

How would you rate your typical stress level?

0 — Very low10 — Extremely high

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How physically active are you?

Rarely activeLight activity 1–2 days/weekModerate activity 3–4 days/weekActive 5+ days/week

How much caffeine do you typically consume each day?

None1 serving2 servings3 servings4+ servings

How often do you drink alcohol?

I do not drink alcoholOccasionally — less than once a week1–3 days per week4 or more days per weekPrefer not to answer

On a typical day when you drink alcohol, approximately how many drinks do you have?

Not applicable — I do not drink1 drink2 drinks3 drinks4 or more drinksIt variesPrefer not to answer

Do you currently use nicotine products? Select all that apply.

CigarettesVaping / e-cigarettesSmokeless tobaccoNicotine gum, patches, or pouchesI do not currently use nicotinePrefer not to answer

14 Medications, Health & Supplements

Are you currently taking any medications or dietary supplements?

NoYes

Are you currently using hormonal birth control?

NoYesPrefer not to answer

Have you ever been diagnosed with any of the following? Select all that apply.

MigraineEndometriosis or adenomyosisUterine fibroidsPCOS or ovarian cystsThyroid disorderAnemia or low iron / ferritinAnxiety or depressionAnother conditionNo known diagnosesPrefer not to answer

During the past three months, have you experienced any major changes that may have affected how you feel? Select all that apply.

Major stressSignificant change in sleep or work scheduleChange in diet or noticeable weight changeNew medication or supplementStarted, stopped, or changed hormonal birth controlIllness or medical procedureFrequent travel or shift workNone of these

How many days per cycle do you usually take pain medication because of menstrual or PMS-related symptoms?

None1–2 days3–4 days5 or more daysIt varies

Do you have any known allergies or sensitivities to foods, herbs, honey, bee products, or dietary supplements?

NoYes

15 Your Biggest PMS Problems

If the difficult days of your cycle became more manageable, which THREE improvements would matter most to you?

What is the hardest part of PMS for you personally?

Is there something PMS does to you that we did not ask about?

16 Your Overall PMS Severity

Taking everything into account, how severe is PMS for you overall?

0 — PMS does not affect my life10 — PMS severely affects my life

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Thank you

Your answers will help us better understand your individual PMS pattern and track how it changes over time.

Please complete this questionnaire before beginning Woman’s Balance.

SAVE YOUR QUESTIONNAIRE

Where can we connect your answers?

Your contact information lets RJV LABS identify your questionnaire and follow your experience over time.

First NameEmailI consent to RJV LABS securely storing my questionnaire responses and using them to understand my PMS pattern and communicate with me about Woman’s Balance.We respect your privacy. You can unsubscribe from communications at any time.