Name *
Name
Date *
Date
The bleeding is:
What color is the blood?
Is there clotting?
Do you have Premenstrual Tension?
Does your face break out premenstrually?
Do you bleed or spot between periods?
Are your menstrual periods spaced irregularly?
Date of your last menstrual period:
Date of your last menstrual period:
Have you ever had an abnormal PAP smear?
Have you ever had a cervical biopsy, cauterization, or conization?
Have you ever had a venereal disease?
Have you ever been diagnosed with a chlamydial infection?
Do you get yeast infections regularly?
Do you have chronic vaginal discharge?
Have you ever had pelvic inflammatory disease?
If YES, were you treated for it?
Date of last PAP smear:
Date of last PAP smear:
Have you ever been diagnosed with ovarian cysts, uterine fibroids or polyps?
Have you ever been diagnosed with endometriosis?
Have you been diagnosed with pelvic adhesions?
Have you been diagnosed with any pelvic abnormalities?
Have your menstrual cycles changed since they began?
Do you ovulate on your own?
Do your breasts get tender at/during ovulation?
Do you get premenstrual back pain?
Do your bowel movements become loose at the beginning of your period?
Have you had fertility treatments?
Have you taken any medication to help you ovulate?
Have your fallopian tubes been evaluated medically?
Have you had any tubal operations?
Have you had your hormone levels checked via lab tests?
Have you taken oral contraceptives?
Have you ever had an IUD?
Have you ever taken DepoProvera?
Have you had a diagnosis related to infertility?
Do you have a single partner with whom you are trying to conceive?
Has he had a fertility workup?
How is your sexual energy?
Do you douche regularly?
Do you use vaginal lubricants?
Are you more than 20% over your ideal body weight?
Are you more than 20% below your ideal body weight?
Do you have a stressful occupation?
Do you exercise regularly?
Do you have excessive facial hair?
Do you have excessively oily skin?
Have you experienced excessive loss of head hair?
Have you noticed discharge from your nipples?
Was you mother exposed to diethylstibestrol (DES) when she was pregnant with you?
Have you been exposed to any known environmental toxins or hormones?
Are you presently taking steroids?