Period Care | Shri Vishwa Kalyan Ayurveda Panchkarma Centre

SAY GOODBYE TO PERIOD PAIN-

THE AYURVEDIC WAY

Name*

Age*

Whatsapp Number *

At what age did your periods start?*

Below 12 years

12-14 years

15-17 years

Above 17 years

Is your menstrual cycle regular ?*

Yes

No

Sometimes Irregular

Average Cycle length( days between periods)*

21-24 days

25-28 days

29-35 days

More than 35 days

How many days does your bleeding last?*

2-3 days

4-5 days

6-7 days

More than 7 days

Do you experience pain during periods? *

Yes

No

When does the pain usually start?*

Before periods

On the first day

During the entire period

After periods

Pain intensity *

Mild

Moderate

Severe

Where do you feel the pain? *

Lower Abdomen

Lower back

Thighs/ legs

Whole body

Do you take pain killers during periods ?*

Yes regularly

Sometimes

No

Have you taken any Ayurvedic treatment before?*

Yes

No

How would you describe your level?*

Low

Moderate

High

Do you exercise regularly?*

Yes

Occasionally

No

Diet preference *

Vegetarian

Mixed

What is your main concern regarding periods?*

Menstrual Pain Assessment Form

Your Personalized Herbal Period Pain Kit is now ready to be Dispatched.

SAY GOODBYE TO PERIOD PAIN-

THE AYURVEDIC WAY

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