August 2014


PMS Self Evaluation Questionnaire (PEQ)  

You may not be sure whether you have PMS or not. You may know that you have PMS but not be sure of the degree that you are actually suffering. To self-evaluate whether or not you have PMS and to determine the degree of your symptoms we have provided a PMS Evaluation Questionnaire (PEQ) below. Using this self-grading system, you can now determine whether you have PMS and the intensity of your own symptoms. In each column we want you to self-score your PMS symptoms. Column 1 represents the degree of symptoms as you see them in the week before your menstrual period. You can use any month you wish. In Column 2 we want you to score the degree of symptoms in the week during your menstrual period. In Column 3 we want you to score your PMS symptoms in the week after your menstruation is complete.

In order to score yourself you must rate your symptoms according to the following scale of 0 to 4:

   0 (Zero) indicates that you are having no occurrence of a particular symptom.
   1 (One) indicates that the symptom you are experiencing are mild, that is they are present but they are no a problem to you. 
2 (Two) indicates that you consider your symptoms to be moderate in nature. You are experiencing them they are significant but tolerable.
3 (Three) indicates that you consider your symptoms to be severe. They are more than just a little uncomfortable, you may need to take medication or they are bothering you to a significant degree. 
4 (Four) indicates that at some time during this period you are partially or completely disabled. You are not able to work, you have to stay at home possibly in bed.

You must judge your own symptoms. We cannot experience what you are experiencing. The system allows you to choose one of five categories: I do not have this symptom, this symptom is mild, moderate, severe or disabling in its intensity.

Rate each symptom separately. You may have some symptoms but not others that is not at all unusual. What is important here is the way you rate those symptoms you experience and giving a 0 to those symptoms that you do not experience.

To take this test it is simplest to print the PEQ form and then enter your scores in the appropriate columns. After you have completely filled numbers in each column and in all of the boxes then please total each of the three columns.

The middle column is not used in the calculations but will give you a sense of your personal PMS pattern.


Self Score Your PMS Symptoms

Rate Your PMS Symptoms

Column 1
Week Before Your Period

Column 2
Week During Your Period

Column 3
Week After Your Period

Nervous Tension




Mood Swings












Weight Gain




Swelling of Extremities




Breast Tenderness








Craving for Sweets




Increased Appetite




Heart Pounding








Dizziness or Fainting




























Total Your Score:




Once you have totaled each column you can determine your scores:

1. Subtract the total from Column 3 from the total from Column 1:

Total from Column 3

Subtract Total from Column 1

Your score is:


Your PMS Rating Is:

If your score is between 0 and 12 you do not have PMS.

If your score is between 12 and 18 you have borderline to mild PMS.

If your score is between 19 and 25 you have mild to moderate PMS.

If your score is between 25 and 35 you have moderate to severe PMS.

If your score is between 35 to 45 you have severe PMS.

If your score is 45 or greater represents disabling PMS.