Sr. No. Question Option Your Answer Question Help 1 Pain, tenderness, enlargement or swelling of breasts 1 2 3 4 5 6 2 Feeling unable to cope or overwhelmed by ordinary demands 1 2 3 4 5 6 3 Feeling under stress 1 2 3 4 5 6 4 Outburst of irritability or bad temper 1 2 3 4 5 6 5 Feeling sad or blue 1 2 3 4 5 6 6 Backaches, joint and muscle pain, or joint stiffness 1 2 3 4 5 6 7 Weight gain 1 2 3 4 5 6 8 Relatively steady abdominal heaviness, discomfort or pain 1 2 3 4 5 6 9 Edema, swelling, puffiness, or water retention 1 2 3 4 5 6 10 Feeling bloated 1 BLOATED = SWELLING 2 3 4 5 6 Your Name Your Age Place Your Address Your Phone Number Your Email ID Suffered from any major illness in last 3 months? Give details Any Other information You can fill up this form and send this excel sheet at shahnehal29@gmail.com