Adopted from: Allen S, et al., work (1999) -

The Shortened Premenstrual Assessment Form. J Reprod Med. 1991;36(11):769-72.

For each of the symptoms below, circle the number that most closely describes the intensity of your premenstrual symptoms during your last cycle. These are symptoms that would occur during the premenstrual phase of your cycle. This phase begins about seven days prior to menstrual bleeding (or seven days before your period) and ends about the time bleeding starts. Rate each item on this list on a scale from 1 (not present or no change from usual) to 6 (extreme change, perhaps noticeable even to casual acquaintances).

1=No change Extreme change=6

A score greater than 30 generally indicates moderate PMS symptoms; the more severe the symptoms, the higher the score


1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

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