Are your menstrual periods irregular?
How long is your menstrual cycle(days between day starting?
How many pads or tampons do you use on your heaviest day?
How old were you when you began menstruation?
ADDITIONAL GYNECOLOGICAL HISTORY
Have you had a mammogram? if yes, when?
Have you had an abnormal pap smear or positive HPV?
Have you taken estrogen, oral contraceptives or other hormones?
Current method of birth control:
HRT or other menopausal use?
Total number of pregnancies*
PAST SURGICAL PROCEDURES (date and location)
PAST MEDICAL-HOSPITAL/EMERGENCY ROOM ADMISSIONS
CANCER HISTORY, SELF AND FAMILY
PAST MEDICAL HISTORY - SELF
PAST MEDICAL HISTORY- FAMILY
History of drug use or abuse?
Describe sleep habits-- hours per night.
Describe your dietary habits.
List other medical history or life style habits that impact your health and well being.
