Females Only Yes No Details Yes No Details Age Periods Began Premature Cycle Length (average Stillbirths # days from first day of period to first day of next period) Period Length Miscarriages Flow Abortions Discomfort Tubal Pregnancy PMS (pre-menstrual Pregnancy syndrome) Complications Number of Vaginal Deliveries Pregnancies (what year/s) Full term Cesarean Sections (what year/s) Medications Please list any medications you are currently taking:___________________________________________ Please list any known drug allergies you have and your reaction to them:
Females Only Yes No Details Yes No Details Age Periods Began Premature Cycle Length (average # days from first day of period to first day of next period) Stillbirths Period Length Miscarriages Flow Abortions Discomfort Tubal Pregnancy PMS (pre-menstrual syndrome) Pregnancy Complications Number of Pregnancies Vaginal Deliveries (what year/s) Full term Cesarean Sections (what year/s) Medications Please list any medications you are currently taking:___________________________________________ Please list any known drug allergies you have and your reaction to them:
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