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FAMILY LIFE:<br />

6. Do you have any natural children?<br />

1. ( ) yes 2. ( ) no<br />

What are their ages? _____________________________<br />

7. Mark with an X the number of hours you work a day in your job/s:<br />

1. ( ) fewer than 6 hours<br />

2. ( ) between 6 and 8 hours<br />

3. ( ) more than 8 hours<br />

4. ( ) I do not work outside the home<br />

8. Mark with an X the number of hours per day that you spend doing<br />

housework:<br />

1. ( ) up to 2 hours<br />

2. ( ) between 2 and 4 hours<br />

3. ( ) more than 4 hours<br />

4. ( ) I do not do housework<br />

YOUR COMMENTS ON THIS SESSION ARE GREATLY APPRECIATED:<br />

MENSTRUAL CYCLE:<br />

9. How long has your menstrual cycle (first day of your period until the last day before<br />

your next period starts) been in the last six months?<br />

1. ( ) less than 21 days<br />

2. ( ) from 22 to 26 days<br />

3. ( ) from 27 to 32 days<br />

4. ( ) from 33 to 35 days<br />

5. ( ) more than 35 days<br />

6. ( ) other patterns of cycles.<br />

10. Do you feel any change or discomfort 5 to 10 days PRIOR to your menstrual flow?<br />

1. ( ) yes 2. ( ) no 3. ( ) sometimes<br />

If the answer to question 10 is NO, please<br />

answer question 15.<br />

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