Medical History Form Page 5
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710815 Bathurst St., Richmond Hill, ON L4C 9Y2
Tel.: 905-737-5559, fax: 905-737-5556
15. FEMALE REPRODUCTIVE
Age menses began
Average number of days
Length of cycle
Bleeding between periods
Y P
N
Are cycles regular
Y P
N
Pain during intercourse
Y P
N
Painful menses
Y P
N
Excessive flow
Y P
N
PMS
Y P
N
Birth control?
Y P
N
What type?
Number of pregnancies
Number of live births
Number of miscarriages
Number of abortions
Difficulty conceiving
Y P
N
Are you sexually active?
Y P
N
Sexual difficulties
Y P
N
Venereal Disease
Y P
N
Sexual preference: Heterosexual
Y P
N
Bisexual
Y P
N
Y P
N
Homosexual
Last menstrual period
Vaginal discharge
Y P
N
Vaginal itching
Y P
N
Last PAP - (date)
16. MUSCULOSKELETAL
Joint pain or stiffness
Y P
N
Arthritis
Y P
N
Broken bones
Y P
N
Muscle spasms or cramps
Y P
N
Weakness
Y P
N
Joint swelling
Y P
N
Backache
Y P
N
17. PERIPHERAL VASCULAR
Deep leg pain
Y P
N
Cold hands/feet
Y P
N
Varicose veins
Y P
N
Thrombophlebitis
Y P
N
Leg cramps
Y P
N
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