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ANEXO II<br />

QUESTIONÁRIO EM INGLÊS PARA OS JUÍZES ESTRANGEIROS<br />

Please only answer this questionnaire if you are between the ages of 18 and 50, have<br />

menstruated regularly for the past 3 months and are not pregnant. It is not necessary<br />

that you identify yourself.<br />

PHYSICAL EXERCISE AND PREMENSTRUAL SYNDROME<br />

Primary data<br />

QUESTIONNAIRE<br />

1. Date of birth: ____________________________________<br />

2. Profession: _________________________________<br />

3. Place of work: ___________________________________<br />

4. Education:<br />

Write an X next to the only choice:<br />

Up to 4 th grade<br />

Up to 8 th grade<br />

Up to 10 th grade<br />

Up to 12 th grade<br />

Undergraduate school - incomplete<br />

Undergraduate school certificate<br />

5. Appliances and amenities that you have at home for your comfort:<br />

Write an X next to all the options according to the number of appliances that you have at home:<br />

Color TV<br />

Videocassette<br />

Radio<br />

Bathroom<br />

Automobile<br />

Full time maid<br />

Vacuum cleaner<br />

Washing<br />

machine<br />

Refrigerator<br />

without freezer<br />

Refrigerator with<br />

freezer or just<br />

freezer<br />

None 1 2 3 4 5 6 or<br />

more<br />

source: ABA - ABIPEME December/97<br />

197

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