| 1. |
How long are you Married? |
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| 2. |
Have you ever been pregnant before? |
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| 3. |
Did you have abortion? |
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| 4. |
Did you take contraceptive pills? |
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| 5. |
Did you take Hormone Tablets? |
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| 6. |
How many days once do you have a Menstrual Cycle? |
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| 7. |
Date of Last Menstrual Period? |
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| 8. |
Number of days Menstrual flow (or) Bleeding. |
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| 9. |
Do you have the Second (or) Third weeks of the Menstrual Cycle? |
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| 10. |
Do you have many menstrual Cycle in every Month? |
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| 11. |
What is the colour of the Bleeding? |
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| 12. |
Whether the Bleeding is Clotted (or) Watery |
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| 13. |
Write about the flow of Menstruation? |
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| 14. |
Is there any Whitish Discharge? |
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15. |
Do you have the Whitish Discharge during the time of Menstrual Cycle? |
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16. |
Do you feel the Whitish Discharge is acrid Smell and Burning Sensation? |
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17. |
Is there any Itching Sensation in the Vagina? |
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18. |
Is there any Stony Hardness (or) Swelling with : tenderness in the Breasts during Menstrual Cyde? |
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19. |
Is there any Abdominal Pain during Menstrual Cycle? |
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20. |
Have you got Abdominal Pain one day before the Menstrual Cycle? |
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21. |
Do you have the Frequent Abdominal pain? |
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22. |
Do you have the Symptom of Nausea, Vomiting and Faint during the time of Abdominal pain. |
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23. |
Do you have the Symptom of Indigestion and Vomiting during the Menstrual Cycle? |
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24. |
Is there any pain from Hip, Thigh and Leg during the time of Menstrual Cycle? |
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25. |
Do you have the Bleeding from other Orifices? : (Vicarious Menstruation), (Nose, Lungs, Vomiting) |
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26. |
Do you feel the Headache during the time of Menstrual Cycle? |
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27. |
Do you have Mental Distress? (Fear, Anxiety, Tension) |
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28. |
Do you feel over Weakness during Menstrual Cycle? |
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29. |
i). What is your Weight?
ii). Are you Obese person |
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30. |
Do you have Regular and Nutritional Diet? |
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31. |
Do you feel fever during Menstrual Cycle? |
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32. |
Is there any burning Micturition? |
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33. |
Is there any burning Sensation During the Inter Course? |
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| 34. |
Have you undergone 0 & C? |
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| 35. |
Do you have interest to do inter course with your Husband? |
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| 36. |
Is there any Watery Secretion (or) Dryness Feeling in the Vagina during Inter Course? |
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