Menstrual History: |
| (please answer the following questions about your menstrual cycle) |
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| How old were you when you first began to menstruate: |
| 10 |
| 11 |
| 12 |
| 13 |
| 14 |
| 15 |
| Other Enter Other: |
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| How many days are there (usually) between one period to the next? |
| 26-28 |
| 29-32 |
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Other Enter Other: |
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| How many days do your periods usually last? |
| 2-3 |
| 4-5 |
| 6-8 |
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Other Enter Other: |
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| Do you ever experience mid-cycle bleeding? |
| Yes |
| No |
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| Your last menstrual period started on what date? |
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| Grade your pain level you experience with your menstrual period as: |
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Very Low |
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Low |
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Moderate |
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High |
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Very High |
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| Would you describe your menstrual cycle as: |
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Regular |
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Irregular |
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| In general, how heavy is your menstrual flow? |
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Light |
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Moderate |
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Heavy |
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Very Heavy |
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| Have you had a Pap Smear within the past 12
months? |
| Yes |
| No |
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| Was result of your Pap Smear within normal limits? |
| Yes |
| No |
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| Have you had a mammagram within the past 12
months? |
| Yes |
| No |
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| Was result of your mammagram within normal limits? |
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Yes |
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No |
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| Have you ever taken, or are you currently taking oral contraceptives? |
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Yes |
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No |
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| If yes, what brand and for how long? |
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| What methods of contraceptive have you used?
Please list and date last used: |
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| Have you ever experienced pain with sexual intercourse? |
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Yes |
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No |
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| If yes, please describe the pain: |
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Female Medical/Surgical History: |
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| Have you been surgically sterilized? |
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Yes |
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No |
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| If yes, please describe: |
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| Have you had any other surgeries in the past? |
| Yes |
| No |
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| If yes, please indicate what surgeries you have had: |
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| Have you ever been hospitalized for anything other than the above listed surgeries? |
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Yes |
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No |
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| If yes, please tell us why you were hospitalized: |
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| Are you allergic to any medications? |
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Yes |
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No |
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| If yes, please tell us what medication you're allergic to: |
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| Do you have any dietary restrictions? |
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Yes |
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No |
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| If yes, what are your dietary restrictions, and for what reason? |
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| Do you take any supplemental vitamins or herbal remedies on a continual basis? |
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Yes |
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No |
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| If yes, please list what vitamins or herbal remedies you are taking: |
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| Do you take any prescription or over the counter medication on a regular or continual basis? |
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Yes |
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No |
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| If yes, please list what medication you are currently taking: |
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| Do you exercise regularly? |
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Yes |
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No |
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Social History |
| Tobacco (Check all that currently apply): |
| I currently smoke |
| I am a heavy smoker |
| I used to smoke but no longer do |
| I have never smoked cigarettes |
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| Alcohol |
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I never drink alcohol |
| I drink times per week |
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I rarely drink alcohol (less than twice a year) |
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| Drug usage: |
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I have never used illegal drugs |
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I have tried illegal drugs at least once in the past |
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I used to do drugs regularly but don't anymore |
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I am currently using one or more of the following: |
| Enter usages: |
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| Have you ever used injectable drugs? |
| Yes |
| No |
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| If yes, when did you last use injectable drugs? |
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| Describe your profession: |
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Male History: |
| (please answer the following questions about the male partner if appropriate) |
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| Any prior children from other partners? |
| Yes |
| No |
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| Are you aware of any health problems with yourself? |
| Yes |
| No |
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| If yes, please indicate those problems: |
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| Ethnicity (check all that apply): |
| AborigineAfrican |
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Asian/Indian
Chinese |
| Caucasian Hispanic |
| Indonesian Mediteranean |
| Native American West Indian |
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Jewish-Ashkenasi
Jewish-Sephardic |
| Other
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| Are there any genetic abnormalities or birth defects in family? |
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Yes |
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No |
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| If yes, please describe: |
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| Is there a prior semen analysis? |
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Yes |
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No |
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| If there was a semen test, was it normal or abnormal? |
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Normal |
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Abnormal |
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| If abnormal, please list defects: |
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| Are you aware of any other health problems in your self, family or previous sexual partners that you have not already disclosed? |
| Yes |
| No |
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| If yes, please indicate those problems you are aware of, that you have not already disclosed to us in this document: |
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I understand that the answers used in this questionnaire will
be used to determine an appropriate treatment plan for me. By clicking Submit, I hereby certify that my answers and explanations,
which were voluntarily given in this questionnaire, are correct. I understand
that the answers used in this questionnaire will
be used to determine an appropriate treatment plan. |
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