4) Women's Health History Name Total pregnancies Live births Living children Miscarriages Abortions Premature births Date of pregnancy Sex --- M F na Weight Length of pregnancy Delivery type Complications --- M F --- M F --- M F Are you trying to get pregnant? --- No Yes Any chance that you are pregnant? --- No Yes Date of last menstrual period What birth control method do you use? Partner is sterile or has had vasectomy Tubal ligation Hysterectomy Cervical cap IUD Diaphragm Condoms Foam Pill Other n/a If Pill, name and # of years taken If Other, please specify Age at start of your menstrual cycle Age at end of your menstrual cycle (menopause) Do you have a regular menstrual cycle? --- No Yes Flow --- Light Medium Heavy How many days? Symptoms associated with your menstrual cycle PMS Migraine Anxiety Irritability Depression n/aAre you sexually active? --- No Yes How would you rate your libido? --- Poor Fair Good Great Do you have more than one sexual partner? --- No Yes Have you ever been tested for HIV and/or AIDS? Have you ever had any Sexually Transmitted Diseases? --- No Yes If Yes, please specify How often do you get screened for STD's? (note: a PAP smear is not an STD test) What do you do to protect yourself from STD's? Enter Code Powered by ChronoForms - ChronoEngine.com
