Women'S Fertility History I - The Caporale Center Of Natural Health
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4CONFIDENTIAL
women’s fertility history I
NAME (LAST, FIRST, MIDDLE)
DATE
WEIGHT
HEIGHT
AGE
AGE AT WHICH MENSES BEGAN
HAVE YOUR CYCLES CHANGED SINCE THEN? IF SO, HOW?
ARE YOUR PERIODS PAINFUL?
HOW LONG DOES THE PAIN LAST?
HOW MANY DAYS DO YOU
HOW MANY DAYS BETWEEN YOUR
DATE OF LAST MENSTRUAL PERIOD
DATE OF LAST PAP SMEAR:
NORMALLY BLEED?
PERIODS?
HOW HEAVY IS THE BLEEDING?
HEAVY
Fill in the chart.
NORMAL
LIGHT
1
2
3
4
5
6
7
8
9
10
DAY
WHAT COLOR IS THE BLOOD?
LIGHT RED
Fill in the chart.
RED
DARK RED
PURPLE
BROWN
BLACK
1
2
3
4
5
6
7
8
9
10
DAY
Please answer yes or no to best describe your current condition.
YES
NO
DO YOU EXPERIENCE CLOTTING?
DO YOU HAVE PREMENTRUAL TENSION / PMS?
DOES YOUR FACE BREAK OUT BEFORE OR DURING YOUR PERIOD?
ARE YOUR BREASTS TENDER PREMENSTRUALLY?
DO YOU BLEED OR SPOT BETWEEN PEIODS?
ARE YOUR MENSTRUAL CYCLES SPACED IRREGULARLY?
IF SO, PLEASE EXPLAIN: _______________________________________________________________________________________________________________
ARE YOUR BREASTS TENDER AT / DURING OVULATION?
DO YOU GET PREMENSTRUAL LOW BACK PAIN?
DO YOU EXPERIENCE LOOSE STOOLS AT THE BEGINNING OF YOUR PERIOD?
Please answer yes, no, or with the number of
YOUR ANSWER
DATE OR YEARS
occurrences.
HOW MANY PREGNANCIES HAVE YOU HAD?
_____________
______________________
HOW MANY CHILDREN DO YOU HAVE?
_____________
______________________
HOW MANY ABORTIONS HAVE YOU HAD?
_____________
______________________
HOW MANY MISCARRAIGES HAVE YOU HAD?
_____________
______________________
HOW MANY TIMES HAS A D&C BEEN PERFOMRED?
_____________
______________________
HOW LONG?
HAVE YOU EVER TAKEN ORAL CONTRACEPTIVES?
_____________
______________________
__________________________
HAVE YOU EVER TAKEN DEPOPROVERA?
_____________
______________________
__________________________
HAVE YOU EVER HAD AN IUD?
_____________
______________________
__________________________
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