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.
  • 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
  • Past Present
    Pill
    Patch
    Diaphragm
    Injection
    Condoms
    IUD/Coil
    Rhythm Method
    Charting Cycles
    Abstinence
    Other
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