qstadnapms

P.M.S. RESEARCH LABORATORY
(800) 272-3436 www.premenstrualsyndrome.com
Fax (310) 777-6989

Due to some hormonal, vitamin and mineral deficiencies,
many women are experiencing a change of sexual desire during premenstrual syndrome..
For this reason the medical team of PMS Research Laboratory has developed this breakthrough treatment:
The SEXDRIVE Pills
This personalized treatment will help you correct changes that occur in your sexual life during your PMS by regularizing and improving your sexual performance.
At the same time it will relieve you from those unwanted symptoms
of PMS such as mood swings, headaches, bachackes, cramps, bloating and much more..
This acclaimed treatment to improve your sexual desire during PMS was formulated by Dr.Marcel Diennet.MD, an internationally recognized expert in health care for woman, researching for the past 25 years the causes, symptoms and solutions on how-to cure women suffering from premenstrual tension.
If you wish to order the Sexdrive Pills
Fill out this questionaire carefully:
The medical team of PMS Research Laboratory
will evaluate your answers and will compound, in our laboratory,
your personalized Sexdrive Pills.
You will receive:
A 30 days treatment to be taken once a day.
Sincerely,
The Research Team of PMS Research Laboratory
directed by Dr.Marcel Diennet,MD.

®P.M.S. ANALYTICAL QUESTIONNAIRE
FOR SEXDRIVE

LAST NAME:

FIRST NAME:

M.I.:

Street:

City/State:

Zip/Country:

Telephone:()Home

E-Mail Address:

Telephone:()Work

Fax:()Fax

Date of Birth: mdy

Married: Yes No

Number of children:

Weight:pounds

1. Monthly periods:

A. Are your periods regular?	no
B. Do you suffer any pain during your period?	yes
C. Do you feel bloated before your period?	yes
D. Do you take any contraceptive pills or hormones: progesterone or estrogen?	yes
D1. Are you bleeding between periods?	yes
D2. Do you think that you would need some hormones: progesterone and estrogen?	yes
E. Do you wear an IUD?	yes
F. Have you ever had a miscarriage?	yes
G. Have you ever had an abortion?	yes
H. Have you been through a partial hysterectomy?	yes
I. Do you have hot flashes?	yes
J. Do you have any cysts in the breast?	yes
K. Do you have any breast pain?	yes
L. Do you suffer from premenstrual syndrome?	yes

2. Blood Circulation:

A. Is your blood circulation normal?	no
B. Do your legs feel heavy at night?	yes
C. Do your veins stand out (varicose veins)?	yes
D. Do you have any reaction to the sun?	yes
E. Do you tolerate heat?	no
F. Do you tolerate cold?	no

3. Sexual problems:

A. Do you have a lower libido?	yes
B. Do you have an excess libido?	yes
C. Frigidity	yes
D. Vaginal dryness	yes
E. Are you sexually aggressive on your PMS?	yes

4. Anxiety, Depression, Nervousness:

A. Do you suffer from nervousness?	yes
A. Are you a "worrier"?	yes
A. Are you often depressed?	yes
B. Do you cry often?	yes
C. Do you suffer from claustrophobia?	yes

5. Sleep:

A. Do you sleep well?	no
B. Do you take sleeping pills?	yes

6. Check when you first experienced a PMS. Check as many as apply:

	A. During puberty.
	B. Just after puberty.
	C. When you first had sexual relations.
	D. At time of marriage or change in lifestyle.
	E. When your children were born.
	F. During periods of emotional problems (illness of children, work problems, death of someone close, separation or divorce.
	G. After hysterectomy.
	H. With the birth control pill.
	I. After abortion.
	J. After miscarriage
	K. After you quit smoking.

7. Blood Tests & Thyroid:

A. Was your latest blood test normal?	no
A. Is your thyroid normal?	no

8. Medical Treatment:

a. Antibiotics	yes
b.Diuretics	yes
c. Appetite suppressant	yes
d. Cardiac medication	yes
e. Cortisone medication	yes
f. Thyroid medication	yes
g. Hormone: Progesterone	yes
h. Hormone: Estrogen	yes
i. Other Medications	yes

9. PMS SYMPTOMS
Check as many as may apply to describe what effects your PMS has on you.

Accident Prone	Aggression & Violence	Anger
Anxiety	Arthristy	Asthma
Attempted Suicide	Backache	Bloating
Blurred Vision	Boils	Breast Engorgement
Breast Tenderness	Bronchitis	Bruises Easily
Capillary Fragility	Child Abuse	Cold Extremities
Cramps	Crying & Weeping spells	Dark circles under eyes
Depression	Difficulty in Concentrating	Diseases
Dry Hair	Dry Skin	Epilepsy
Excess use of alcohol	Exhaustion-Mental/Physical	Eye Irritation
Eye Puffiness	Facial pallor	Fainting Spells
Fatigue	Feelings of being crazy	Feelings of Panic
Flu & Cold	Food Cravings	Frequent Urination
Frustrations	Gained Weight	Gall Bladder Symptoms
Gas	Greasy Hair	Hair Loss
Headaches	Herpes Simplex No 1	Hoarseness
Hypoglycemic	Hysteria	Inability to concentrate
Infection	Infertility	Insomnia
Irritability	Joint Inflammation	Joint Muscle Pain
Lack of Appetite	Leg & Muscle Cramps	Lethargy
Lowered Libido	Migraines	Mood swings
Motor Coordination	Poor Dream Recall	Runny Eyes
Runny Nose	Self Inflicted Injuries	Sinusitis
Sleep Disturbances	Slow Digestion	Sore Throat
Spontaneous Abortion	Stiffness	Sudden Anger
Traction	Upper Respiratory Problems	Water Retention
Weight Gain	White Spots in fingernails	Nympho Mania

Have you ever been on the PMS Program?

yes

If "yes", how did it work?

Why did you stop?

Please provide your credit card information: In order for us to get your product to you as soon as possible,
Price: $45.00

BILLING

Credit card

Cardholder name

Card number

Expiration date

The cardholder agrees that PMS Research Laboratory will automatically bill the subscriber credit card.
Yes, I agree.

Yes No

By check or money order to:

            PMS Research Laboratory
            9454 Wilshire blvd. Ste # 314
            Beverly Hills, CA 90212

I hereby certify that the above information is accurate and that I take the responsibility

for the whole program.

            Signature:
            Date:
            Referred By:
            Attendant:

P.M.S.RESEARCH LABORATORY
(800) 272-3436
Fax (310) 777-6989
Please send e-mail to:PMS@PREMENSTRUALSYNDROME.COM

	BILLING
*Credit card*
*Cardholder name*
*Card number*
*Expiration date*