Menstrual History

Menstrual History

First Name*
Last Name*
Address*
City*
State*
Zip Code*
Age*
Email*
Phone*

1.

Age of menarche
(age you started your periods)

2.

Is the length of your menstrual cycle:
regular or irregular?

3.

Do you have PMS (premenstrual syndrome), i.e., increased irritability, depressed mood, easily teary-eyed, moody? yes no

4.

Do you have headaches around the time of your period? yes no

5.

Do you have breast pain/tenderness with your period? yes no

6.

Do you have cramps with your period?
yes no

How severe are they?

7.

How heavy is the flow?

8.

How many days do you bleed?

9.

Do you spot at the beginning, end, or between your periods?

10.

Do you have clots? yes no

How big are they?

11.

Do you have acne? yes no
Is it worse just before or
during your periods?

12.

Do you have excess and/or coarse hair on your face, chest, breasts, or below your belly button? yes no

13.

Do you have lumps and/or cysts in your breasts? yes no

14.

Are you taking any kind of birth control pills/patches/shots? yes no

If so, what kind?

Physicians' Medical Center of the Ozarks · 17 Medical Plaza · Mountain Home, AR 72653
Toll-Free 1-866-749-7633 · (870) 425-6212 · Fax (870) 424-3774 · www.physmedcenter.com