Heaviness of the bleeding |
Amount of bleeding |
Frequency of menstrual product changes |
Bleeding through clothes |
Passage of blood clots |
Duration of the bleeding |
Pattern of the bleeding |
No. of days between periods |
Whether or not periods are “predictable” |
Quality of life |
Changed daily routine because of bleeding |
Bleeding affects her quality of life |
Missed work because of bleeding |
Changed social plans because of bleeding |
Mood related to bleeding |
Anxiety related to bleeding |
Depressed moods related to bleeding |
Patient expectations |
Patient expectation for results of treatment |
Other questions/symptoms/bleeding disorders |
Dysmennorhea |
Weakness |
Whether the patient has had other problems with bleeding such as during pregnancy, with delivery, or when brushing teeth |