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P.M.S. RESEARCH LABORATORY

(800) 272-3436 www.premenstrualsyndrome.com Fax (310) 777-6989
By filling out this questionnaire,
you authorize the research team of PMS.R.L.
directed by Dr. Marcel Diennet,M.D to study your personal case of PMS
and to give you their medical opinion.
If you wish to order your PMS PROFILE
Carefully fill out the questionnaire, after the evaluation you will receive:
A detailed diagnostic of your special case of PMS,
and an explanation on the way to get rid of the symptoms.
It will give you all the information that you will need to treat your PMS
and will drive you all the way to cure it.

®P.M.S. ANALYTICAL QUESTIONNAIRE
FOR PMS PROFILE

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:when you are not on PMS.

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
3. Higher libido on PMS	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
D. Are you more nervous on PMS?	yes

5. Anxiety:

A.Usually are you a "worrier"?	yes
B. Do you smoke ?	yes
C. Do you smoke more during PMS?	yes
D. Are you more worry on PMS?	yes

6. Depression:

A. Are you often depressed?	yes
B. Do you cry often?	yes
C. Do you suffer from claustrophobia?	yes
D. Are you more depressed on PMS?	yes

7. Sleep: when you are not on PMS.

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

8. Check when you first experienced a symptom of 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

Are you presently on a P.M.S.program?

yes no

11. Medical Treatment:

A. Are you presently under any medical treatment?

yes

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	Paranoia
Hyper sexual	Arthristy	Asthma
Attempted Suicide	Backache	Bloating
Blurred Vision	Boils	Breast Engorgement
Breast Tenderness	Bronchitis	Bruises Easily
Capillary Fragility	Child Abuse	Cold Extremities
Cramps	Weeping spells	Dark circles under eyes
Depression	Difficulty in Concentrating	More frequent 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	Fever	Gall Bladder Symptoms
Gas	Greasy Hair	Hair Loss
Headaches	Herpes Simplex No 1	Hoarseness
Hypoglycemic	Hysteria	Bladder infection
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
Vaginal hyper secretion

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: $ 27.00

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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

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