Women'S Fertility History I - The Caporale Center Of Natural Health Page 2

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CONFIDENTIAL 
women’s fertility history II
NAME (LAST, FIRST, MIDDLE)
DATE
Have you ever been diagnosed with or experienced the
Please provide the number of occurrences, years / dates they occurred
following?
when applicable and any additional information that would be
beneficial to the physician in determining your treatment plan.
YES
NO
NUMBER
DATES
ADDITIONAL NOTES / INFORMATION
ABNORMAL PAP SMEAR
________
__________________
_______________________________
ENDOMETRIOSIS
________
__________________
_______________________________
LOW FSH
________
__________________
_______________________________
PCOS
________
__________________
_______________________________
PELVIC ABNORMALITIES
________
__________________
_______________________________
LOW IRON
________
__________________
_______________________________
ANEMIA
________
__________________
_______________________________
LOW PROGESTERONE
________
__________________
_______________________________
LOW ESTROGEN
________
__________________
_______________________________
PELVIC ADHESIONS
________
__________________
_______________________________
PELVIC INFLAMMATORY DISEASE
________
__________________
_______________________________
UTERINE FIBROIDS
________
__________________
_______________________________
POLYPS
________
__________________
_______________________________
CYSTS
________
__________________
_______________________________
HEP C
________
__________________
_______________________________
GENITAL HERPES
________
__________________
_______________________________
EARLY MENOPAUSE
________
__________________
_______________________________
CHLAMYDIAL INFECTION
________
__________________
_______________________________
VENERAL DISEASE
________
__________________
_______________________________
REGULAR / FREQUENT YEAST INFECTIONS (provide number per year)
________
__________________
_______________________________
CHRONIC VAGINAL DISCHARGE
________
__________________
_______________________________
SORES ON GENETALIA
________
__________________
_______________________________
CERVICAL BIOPSY,OPERATION, CAUTERIZATION OR CONIZATION
________
__________________
_______________________________

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