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Name:
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Birthday:
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Address:
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Email Address:
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Female Reproductive
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At what age did your period begin?
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What is the average number of days that your period lasts?
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Do you bleed between periods?
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Are your cycles regular?
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How many tampons or pads do you use per day?
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Have you ever noticed any clots during your period?
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If yes, what is the size of the clot?
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Do you experience any of the following premenstrual syndromes?
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Bloating:
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Breast tenderness:
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Mood changes:
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Cravings:
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Cramps:
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Skin changes:
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When was your last menstrual period?
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Do you have any vaginal discharge?
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Do you experience vaginal itching?
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When was your last PAP (date)?
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Are you sexually active?
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Are you on birth control?
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What type?
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How many times have you been pregnant?
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Have you ever had a miscarriage?
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Have you ever had an abortion?
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Do you experience pain during intercourse?
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Have you ever had a sexually transmitted disease?
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What is your sexual preference?
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At what age did you notice breast development?
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Do you have breast lumps?
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Do you experience breast pain or tenderness?
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Have you ever noticed nipple discharge?
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