| 1) Date of birth (D/M/Y): __________Weight_______ Height______ |
| Race (_) White__(_) Non-white |
| 2) Level of schooling |
| (_) Elementary School (1st – 8th grade)__(_) Middle/High School |
| (_) Higher education__(_) Complete__(_) Incomplete course:_____________________ |
|
Sports history
|
| 3) Modality: ____________ |
| 4) Age at start of competitive training: _______ years |
| 5) Hours of training per day, currently: ______ hours |
| 6) Weekly frequency of practice, currently:__________ days/week |
|
Menstrual antecedents
|
| 7) Age at first menstruation: ______ years |
| 8) Do you practice while menstruated? (_) Yes__(_) No |
| 9) How many days does your menstruation last? _____ days |
| 10) How long afterwards do you menstruate again? |
| (_) I don’t know because it varies a lot |
| (_) I don’t know, but I menstruate once a month |
| (_) After ____ days |
| 11) Have you gone 3 months (or more) without menstruating? (_) Yes__(_) No |
| 12) If yes: was it during a period of intensive training? (_) Yes__(_) No |
| Were you lower than your normal weight? (_) Yes__(_) No |
| Did your period normalize once the rhythm of training decreased? (_) Yes__(_) No |
| Did it normalize when you gained weight? (_) Yes__(_) No |
| It is not associated with training or change in weight (_) |
|
Influence of menstrual cycle on performance
|
| 13) Does your coach know when you are in your menstrual period? (_) Yes__(_) No |
| 14) Does your coach agree to change your training if menstruation is interfering with your performance? (_) Yes__(_) No__(_) I don’t tell the coach or talk to him/her about it |
| 15) If you could choose a time to compete, you would choose: |
| (_) My menstrual period does not influence me__(_) Not during menstruation |
| (_) Right before menstruation__(_) During menstruation |
| (_) Right after menstruation__(_) More or less 15 days after menstruation |
|
PMS
|
| 16) What do you feel before your menstrual period? Attribute a score: 1 (if it does not bother you) or 2 (if it bothers you a lot). |
| (_) I do not feel anything that really bothers me __ |
| (_) Pain or swelling in the breasts __ |
| (_) Swelling in my belly, feeling of weight or discomfort __ |
| (_) Headache __ |
| (_) Swelling in hand or legs __ |
| (_) Increase in body weight __ |
| (_) Pain the back, joints, or muscles __ |
| (_) Irritation, nervousness, or sadness __ |
| (_) Increase in appetite __ |
| (_) Changes in sleep __ |
| (_) Lack of concentration, loss of motivation __ |
| (_) Menstrual cramps __ |
|
Sexual history
|
| 17) Have you had sexual relations with men? (_) Yes__(_) No |
| 18) If yes, how old were you “in the first time”? _______ years |
| 19) How many partners have you had? _______ |
| 20) Do you have a fixed partner (you have intercourse only with this person)? (_) Yes__(_) No |
| 21) If “yes”, for how long? __________ |
| 22) Have you had sexual relations with women? (_) Yes__(_) No |
| 23) Do you use any contraceptive method? (_) Yes__(_) No |
| 24) If “yes”, mark the correct option: |
| (_) Pill:__________(_) IUD with progesterone__(_) Male condom |
| (_) Injection once a month__(_) Copper IUD__(_) Female condom |
| (_) Injection every 3 months__(_) Vaginal ring__(_) Other_______________ |
| 25) Was it prescribed by a gynecologist? (_) Yes__(_) No |
| 26) Started to use it to: (_) Avoid pregnancy__(_) Regulate menstruation__(_) For both reasons |
| 27) Do you know what a STD is? (_) Yes__(_) No |
| 28) Have you ever had to treat any sexually transmitted disease? (_) Yes__(_) No |
| 29) If “yes”: |
| Which disease? ___________________________________ |
| What was the treatment? ________________________________ |
| Were you cured? (_) Yes__(_) No |
|
Obstetric history
|
| 30) Have you ever been pregnant?: Yes (_)__No (_)__How many times? __________ |
| Number of deliveries (write the number): (_) Normal__(_) C-section__(_) Forceps |
| Number of abortions (write the number): (_) Spontaneous/Miscarriage__(_) Provoked |
|
Female athlete triad
|
| 31) Have you ever heard of the “female athlete triad”? Yes (_)__No (_) __________ |
| 32) Have you ever had a stress fracture? (A fracture not associated with trauma, accident, or acute torsion) (_) Yes (_) No |
| 33) If “yes”, at that time: |
| Were you menstruating normally? (_) Yes__(_) No__(_) I don’t remember |
| Had you lost weight? (_) Yes _______kg__(_) No__(_) I don’t remember |
| Were you at a time of intense training? (_) Yes__(_) No__(_) I don’t remember |
| In which region of the body did it occur? __________________________ |
|
Past medical/surgical history
|
| 34) Are you under treatment for any disease? (_) Yes__(_) No.__Which ?_________________________ |
| 35) Do you regularly take any medication? (_) Yes__(_) No.__Which?_______________ |
| 36) Have you had any operations? (_) Yes__(_) No.__Which?_____________When? ________ |
| 37) Are you allergic to any food or medication? (_) Yes__(_) No |
| 38) If “yes”, to what? _______________________________________ |
| 39) Do you have routine gynecological accompaniment (at least once a year)? (_) Yes__(_) No |
