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P.M.S. RESEARCH LABORATORY
   (800) 272-3436    www.premenstrualsyndrome.com     Fax (310) 277-7120

Many researches have suggested that the causes of premenstrual syndrome are due
to a hormonal, vitamin and mineral deficiencies.
Every person suffering from PMS has different deficiencies.
For this reason the medical team of PMS Research Laboratory has developed this breakthrough treatment:
                                     PMS Diet Pills
This personalized treatment will help you to correct the hormonal, vitamin and mineral deficiencies created by the premenstrual syndrome.
This treatment relieves you from headaches, backache, menstrual cramping, breast tenderness
and the weight gain due to water retention during PMS.
This acclaimed treatment for women who are experiencing premenstrual tension was formulated
by Dr.Marcel Diennet.MD, an internationally recognized expert in health care for woman,
researching for the past 25 years the causes, symptoms and solutions on how to cure women suffering from premenstrual syndrome.
Fill out this questionnaire carefully
PMS Research Laboratory will evaluate your questionnaire
and compound in our laboratory a personalized PMS Diet treatment for you to live better during PMS.
You will receive :
A 10 days treatment of combined ingredients,
made to your specifications to be taken 1/day in the morning during
the first 10 days of your PMS.
(from the 14th day to the 24th day of your premenstrual syndrome)

Sincerely,
The Research team of PMS.R.L
directed by Dr.Marcel Diennet,MD.

®P.M.S. DIET ANALYTICAL QUESTIONNAIRE
   FOR PMS DIET

LAST NAME:

FIRST NAME:

M.I.:

Street:

City/State:

Zip/Country:

Telephone:()Home

E-Mail Address:

Telephone:()Work

Fax:()Fax

Date of Birth: mdy

Married: Yes No

Number of children:

Weight:pounds

1. Monthly periods:

A. Are your periods regular?	no
B. Do you suffer any pain during your period?	yes
C. Do you feel bloated before your period?	yes
D. Do you take any contraceptive pills or hormones: progesterone or estrogen?	yes
D1. Are you bleeding between periods?	yes
D2. Do you think that you would need some hormones: progesterone and estrogen?	yes
E. Do you wear an IUD?	yes
F. Have you ever had a miscarriage?	yes
G. Have you ever had an abortion?	yes
H. Have you been through a partial hysterectomy?	yes
I. Do you have hot flashes?	yes
J. Do you have any cysts in the breast?	yes
K. Do you have any breast pain?	yes
L. Do you suffer from premenstrual syndrome?	yes

2. Blood Circulation:

A. Is your blood circulation normal?	no
B. Do your legs feel heavy at night?	yes
C. Do your veins stand out (varicose veins)?	yes
D. Do you have any reaction to the sun?	yes
E. Do you tolerate heat?	no
F. Do you tolerate cold?	no

3. Other problems:

A. Are you often constipated?	yes
B. Do you treat it in any way?	no
C. Sexual problems: 1. Frigidity	yes
2. Vaginal dryness	yes
3. Higher libido on PMS	yes

4. Nervousness:

A. Do you suffer from nervousness?	yes
B. Do you bottle everything up inside you?	yes
C. Do you let off steam easily?	yes
D. Are you more nervous on PMS?	yes

5. Anxiety:

A.Usually are you a "worrier"?	yes
B. Do you smoke ?	yes
C. Do you smoke more during PMS?	yes
D. Are you more worry on PMS?	yes

6. Depression:

A. Are you often depressed?	yes
B. Do you cry often?	yes
C. Do you suffer from claustrophobia?	yes
D. Are you more depressed on PMS?	yes

7. Sleep:

A. Do you sleep well in general?	no
B. Do you take sleeping pills?	yes

8. Personal Habits:

A. Do you eat too much? yes

B. Do you eat sweets?. yes

C. Are you a compulsive chocolate eater? yes

D. Are you an obsessive eater?. yes

E. Do you snack between meals?. yes

F. Do you use any drugs?.... yes

G. Do you have more than 3 drinks per day (wine or liquor)? yes

H. Do you eat more during PMS? yes

I. Do you eat more sweets during PMS? yes

J. Do you snack more between meals during PMS? yes

K. Are you more a compulsive chocolate eater during PMS? yes

9. Check when you first experienced a symptom of PMS. Check as many as apply:

	A. During puberty.
	B. Just after puberty.
	C. When you first had sexual relations.
	D. At time of marriage or change in lifestyle.
	E. When your children were born.
	F. During periods of emotional problems (illness of children, work problems, death of someone close, separation or divorce.
	G. After hysterectomy.
	H. With the birth control pill.
	I. After abortion.
	J. After miscarriage
	K. After you quit smoking.

10. Blood Tests:

A. Was your latest blood test normal?

11.Thyroid:

A. Is your thyroid normal?

COMMENTS: Please press enter when arriving at the end of the text window.

A1. Is your pulse normal?	no
B. Are you deficient in calcium?	yes
C. Are you deficient in magnesium?	yes

Are you presently on a P.M.S.program?

yes no

12. Medical Treatment:

A. Are you presently under any medical treatment?

yes

a. Antibiotics	yes
b. Diuretics	yes
c. Appetite suppressant	yes
d. Cardiac medication	yes
e. Cortisone medication	yes
f. Thyroid medication	yes
g. Hormone: Progesterone	yes
h. Hormone: Estrogen	yes
i. Other Medications	yes

Have you ever been on the PMS Program?

yes

If "yes", how did it work?

Why did you stop?

Please provide your credit card information: In order for us to get your product to you as
soon as possible,
Price: $ 99.00

BILLING

Credit card

Cardholder name

Card number

Expiration date

The cardholder agrees that PMS Research Laboratory will automatically bill the subscriber
credit card.

Yes, I agree.

Yes No

Where did you hear about PMS Research Laboratory ?

Special Instructions, if any:

By check or money order to :

           PMS Research Laboratory
           9454 Wilshire blvd. Ste #314
           Beverly Hills , CA 90212

I hereby certify that the above information is accurate and that I take the responsibility
for the whole program.

P.M.S.RESEARCH LABORATORY
(800) 272-3436 Fax (310) 277-7120
Please send e-mail to:PMS@PREMENSTRUALSYNDROME.COM

A. Do you eat too much?	yes
B. Do you eat sweets?.	yes
C. Are you a compulsive chocolate eater?	yes
D. Are you an obsessive eater?.	yes
E. Do you snack between meals?.	yes
F. Do you use any drugs?....	yes
G. Do you have more than 3 drinks per day (wine or liquor)?	yes
H. Do you eat more during PMS?	yes
I. Do you eat more sweets during PMS?	yes
J. Do you snack more between meals during PMS?	yes
K. Are you more a compulsive chocolate eater during PMS?	yes

	BILLING
*Credit card*
*Cardholder name*
*Card number*
*Expiration date*