North Bay Naturopathic Clinic

Supplemental Adolescent Intake Form Female

Name:
Birthday:
Address:
Email Address:

Female Reproductive

At what age did your period begin?
What is the average number of days that your period lasts?
Do you bleed between periods?
Are your cycles regular?
How many tampons or pads do you use per day?
Have you ever noticed any clots during your period?
If yes, what is the size of the clot?

Do you experience any of the following premenstrual syndromes?

Bloating:
Breast tenderness:
Mood changes:
Cravings:
Cramps:
Skin changes:
When was your last menstrual period?
Do you have any vaginal discharge?
Do you experience vaginal itching?
When was your last PAP (date)?
Are you sexually active?
Are you on birth control?
What type?
How many times have you been pregnant?
Have you ever had a miscarriage?
Have you ever had an abortion?
Do you experience pain during intercourse?
Have you ever had a sexually transmitted disease?
What is your sexual preference?
At what age did you notice breast development?
Do you have breast lumps?
Do you experience breast pain or tenderness?
Have you ever noticed nipple discharge?