Informed consent

* 1. Informed Consent for Premenstrual Syndrome (PMS) Research Survey

You are being invited to participate in a research Survey of Premenstrual Syndrome (PMS). Women about 90% of their reproductive age are affected by this health problem emotionally and physically. If you have a history relating to the occurrence of cyclical mood and behavior changes with menstruation in addition to somatic symptoms of painful breast, and/or bloating and/or headaches. You may have been suffering from PMS.

Phoenix Institute of Herbal medicine & Acupuncture (PIHMA), an accredited college in Asian Medicine with a teaching clinic, has been successfully treating PMS for many years. We are preparing a study of Premenstrual Syndrome (PMS) Research Survey. The objective of this survey is to understand the prevalence of PMS in Phoenix Area, a woman’s attitude towards PMS and herbal medicine and acupuncture, as well as the possible risk factors associated with PMS. Through your participation, we eventually hope to acquire the scientific information to educate young women and mothers to improve their understanding about PMS for better life management in the future. We also hope to enhance the clinical practice in our clinic. Moreover, if you have PMS, you have the opportunity to participate in the following PMS treatment study using acupuncture and/or herbal medicine. In addition, if you do not have the symptoms mentioned above, the information collected may not benefit you directly, but the information learned in this survey should provide more general benefits.

There are no known risks if you decide to participate in this research survey. There are no costs to you for participating. The information you provide will help with the research program for the Foundation for PIHMA Research & Education and the graduate students PIHMA college. The questionnaire will take about 10 minutes to complete. To participate, you must be at least 20 years old and below 50 years old.

Participation in this survey is voluntary. By completing the questionnaire, you are voluntarily agreeing to participate. You are free to decline to answer any particular question if you do not wish to answer for any reason.

If you have any questions regarding the survey, please contact Dr. Jianying He, MD (China), Ph.D., The Foundation for PIHMA Research & Education. Phone 602-795-6970 or email

As a Thank You for completing the survey, please print out this page or the thank you page at completion. Bring the page to PIHMA at 301 E. Bethany Home Road A-100, Phoenix, 85012 for a free auricular acupuncture treatment on Thursdays from 5-7 pm. Thank you!