Women'sHealth HistoryPlease enable JavaScript in your browser to complete this form.Today's DateName *FirstLastSexChoice 4MaleFemaleOtherBirthdayMM/DD/YYYYPhoneXXX-XXX-XXXXEmail *AgeHeightfeet' and inches"Weight (lbs)poundsHas Your Weight Changed in the Past Year?Choice 3YESNOIf YES, How Much?poundsBlood Pressure (without medication)Systolic/DiastolicResting PulseNumber of Pregnancies:Number of Miscarriages:Number of Abortions:Number of Children Born:Number of Living Children:Ages of Living Children:Age when Menstrual Periods Began:How Frequent are Periods?How long do they last?Excessive Flow?YESNOSpotting Between Periods?YESNOPain/Cramps During Period?YESNOBlood Clots During Periods?YESNOIf YES, What Color?Sharp Pain in Ovaries?YESNOIf YES, Which Side?Lumps Found In:BreastArmpitGroin AreaNo Lumps FoundBreast Health:Breast CystsLumpsFibrocystic BreastsNo Problems DetectedHysterectomy?YESNOIf YES, When?MM/DD/YYYYAre You Currently Taking Birth control Pills?YESNOIf Yes, Is This Primarily for Birth Control?YESNOIf No, Why Prescribed?Have You Ever Taken Birth Control Pills in the Past?YESNOIf YES, For How Long?If You Have Since Stopped Taking Birth Control Pills When Did You Stop?MM/DD/YYYYHave You Worn An IUD?YESNOIf YES, For How Long?If You No Longer Wear An IUD, When Did You Stop?MM/DD/YYYYPlease use this space to write in any other important health consideration you may have specific to gender. Please be as specific as possible. *Submit