qstadnapms

P.M.S. RESEARCH LABORATORY
(800) 272-3436 www.premenstrualsyndrome.com
Fax (310) 777-6989
THE PRE-MENSTRUAL INDIVIDUALLY CUSTOMIZED PILL
WAS DEVELOPED BY THE PHARMACEUTICAL TEAM INOURLABORATORIES TO HELP WOMEN
CURE THE UNWANTED SYMPTOMS THAT OCCURS DURING PMS
AND AMELIORATE THE MENSTRUAL CYCLE..
IF YOU WISH TO ORDER THE PINK PILL .
FILL OUT THIS QUESTIONNAIRE CAREFULLY.
YOU WILL RECEIVE:
A 28 DAY TREATMENT TO BE TAKEN ONCE A DAY DURING THE 28 DAYS STARTING THE FIRST DAY OF YOUR MENSTRUATION.
THIS TREATMENT IS SPECIALLY MADE FOR YOU TO CURE THOSE SPECIFIC SYMPTOMS YOU ARE SUFFERING FROM DURING PMS..
SINCERELY,
THE RESEARCH TEAM OF PMS R.L.

®P.M.S. ANALYTICAL QUESTIONNAIRE
For THE PINK PILL

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. Other problems:

A. Are you often constipated?	yes
B. Do you treat it in any way?	no
C. Sexual problems: 1. Frigidity	yes
2. Vaginal dryness	yes

4. Nervousness:

A. Do you suffer from nervousness?	yes
B. Do you bottle everything up inside you?	yes
C. Do you let off steam easily?	yes

5. Anxiety:

A. Are you a "worrier"?	yes
B. Do you smoke ?	yes
C. Do you want to quit smoking?	yes

6. Depression:

A. Are you often depressed?	yes
B. Do you cry often?	yes
C. Do you suffer from claustrophobia?	yes

7. Sleep:

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

8. 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.

9. Blood Tests:

A. Was your latest blood test normal?

10.Thyroid:

A. Is your thyroid normal?

COMMENTS: Please press enter when arriving at the end of the text window.

A1. Is your pulse normal?	no
B. Are you deficient in calcium?	yes
C. Are you deficient in magnesium?	yes

11. Medical Treatment:

A. Are you presently under any medical treatment?

yes

B. If yes, are you taking any of the following:

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

12. 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 for one month
         or:$ 99.00 for 3 months

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

Where did you hear about PMS Research Laboratory ?

Special Instructions, if any:

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.

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

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

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