1.
Do you suffer from any of the following symptoms approximately 1 week before menstruation: anxiety, depression, mood swings, fatigue, cravings, weight gain, swollen and painful breasts, cramps, backache, headaches, bloating?
usually some or most of the above
occasionally some symptoms
seldom /never
2.
How many meals (including snacks) do you eat daily?
1 – 2
3 – 4
5 – 6
3.
How often do you eat fresh fruit and vegetables?
seldom / never
1 – 2 daily
3 or more daily
4.
How often do you eat wholegrain foods (wholewheat or brown bread, high fibre breakfast cereals e.g. All bran or Weetbix)?
seldom / never
often
daily
5.
How often do you eat sugary foods like jam, sweets, chocolates or sugary cold drinks?
daily
occasionally
never
6.
How often do you eat fatty foods (fried or oily foods, salad dressings, margarine, butter etc)?
often
a few times a week
seldom / never
7.
Do you add salt to your food?
always / most of the time
seldom / never
8.
How often do you drink tea (excluding herbal), coffee or cola beverages?
more than 2 per day
1 – 2 per day
seldom / never
9.
Do you exercise regularly (30 – 45 minutes, 3 –4 times per week)?
seldom / never
1 – 3 times most weeks
always
10.
10. Do you smoke?
yes
no
11.
Do you drink alcohol?
most days
1 - 3 times per week
seldom / never
12.
Do you regularly take supplements of vitamin E, Evening Primrose Oil, vitamin B6 or Magnesium?
no
some of the above
all of the above.
