Name:___________________ Age:____ Height:_______ Weight:____
Grading of Menses:
0-none 1-slight 2-moderate 3-heavy 4-very heavy
Grading of Symptoms (Complaints):
0-none
1-Mild: Present but does not interfer with activities.
2-Moderate: Present but interferences with activities is not disabling.
3-Severe-disabling: Unable to function.
From: Abraham G.E.: Nutritional Factors in the Etiology of the Premenstrual Tension Syndromes. J. Reprod. Med. 28:446-464., 1983 A:PMSQu-2.
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