EmailMeForm
Female Reproductive Health History Form
All information provided is confidential and your privacy is respected at all times. Please note that uterine massage cannot be performed five days before and during your menstrual cycle, within 2-3 months of abdominal surgery, if you have an active infection or if there is an intra-uterine device present. Please keep this in mind when booking your appointment, and don't hesitate to email Samar if you have any questions.
Client Name
Email Address
How old were you when you began menstruating? What was your experience of this?
If applicable, please describe your current menstrual cycles in terms of length, duration, quality, comfort levels and experience. Please state the date on which your last menstrual cycle began.
Have you had an episodes of amenorrhea (missed cycles)? If yes, please describe.
When was your last pap/cervical smear test? Please list the results if applicable.
Please select any symtpoms applicable to you.
Past
Present
Painful/Irregular Ovulation or Menses
Dark Thick Blood with Menses
Premenstrual Syndrome (including but not limited to bloating, water renention, depression, mood distrubances, headaches, migraines and/or dizziness)
Varicosities
Numb/Tired/Sore Legs, Heels or Feet
Lower Back Pain
Constipation
Endometriosis/Endometrisis
Bladder Infections/Irritation/Incontinence
Fibroids/Polyps
Uterine Infections
Sexually Transmitted Disease
Incomptent Cervix
Spotting With Pregnancy
Pelvic Inflammation
Dry Vagina
Excessive Bleeding
Breast/Ovarian Cysts or PCOS
Painful Intercourse
Excessive Vaginal Discharge
Vaginitis
Chronic Miscarriages
Weak Newbrns/Premature Deliveries
Please choose your level of interest in sex.
High
Moderate
Low
Do you have a history of sexual abuse? Please elaborate at whatever level of detail you feel comfortable. If you received counseling for sexual abuse, please include your experience of this.
Methods of Contraception You Have Used
Past
Present
Pill
Patch
Diaphragm
Injection
Condoms
IUD/Coil
Rhythm Method
Charting Cycles
Abstinence
Other
Are you currently pregnant or trying to conceive?
Are you currently receiving treatment for infertility or have you undergone IUI/IVF treatments? Please elaborate.
Have you ever been pregnant? If yes, please list the dates and conclusions of each pregnancy (i.e. birth, termination or miscarriage).
Please include any complications or interventions you experienced. Describe how the pregnancy, labor, birthing and post-partum periods were for you physically and emotionally. Include where you chose to give birth, and whether or not you breastfed.
Were you on any medications during pregnancy, labor, delivery or the post-partum phase? Please list. If known, include any medications your mother took while pregnant with or breastfeeding you.
Do you have a maternal family history of any of the following conditions?
Fibroids
Infertility
Miscarriages
Endometriosis
Menstrual Irregularities
Premenstrual Syndrome
Reproductive Cancers
Difficulties with Menopause
If applicable, when did you begin perimenopause / menopause? Please describe your experience of this process, including any symptoms you experienced or may be currently having. Include any medications or remedies you took during this time (including HRT).
Symptoms Experienced During Menopause
Hot Flashes
Vaginal Discharge
Changes in Libido
Dry Vagina
Flooding
Disturbed Sleep
Fatigue
Insomnia
Depression
Irregular Menses
Memory Loss
Anxiety
Painful Intercourse
Mood Swings
Irritability
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