Women's Health Form
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Email *
Full Name
Age of menstrual onset
Date of last period
MM
/
DD
/
YYYY
Date of last GYN exam
MM
/
DD
/
YYYY
Any abnormalities?
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If yes, please describe:
Are you using any form of birth control?
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If yes, please describe. How long:
Describe your menstrual cycles (Select all that apply):
How many days does your menstrual period last?
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Is your menstrual flow
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Describe symptoms you have before or during your period. (Select all that apply):
Do you have any bleeding or discharge outside your menstrual cycle?
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Do you have any vaginal itching:
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Are you currently pregnant?
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Do you plan on getting pregnant in the next year?
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Number of pregnancies
Number of children
Describe any complications with pregnancy:
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