Please fill in all relevant information.
* NOTE * You must expand each section to fill out the information
Smoking, alcohol, drugs, abuse
exercise and diet
GYNECOLOGIC HISTORY (Please check all that are relevant)
If pre-menopausal (still menstruating):
If post-menopausal (no longer menstruating):
FAMILY HISTORYPlease check if there is a family history of any medical problems below (mother, father, siblings, grandparents, aunts, uncles, cousins) for both maternal (mother's) or paternal (father's) side.
Please type family member next to problem, i.e. mother, father, etc., and use (M) for maternal and (P) for paternal.
Check if you CURRENTLY have problems with any of the following (by submitting this form, you are stating that anything left blank is answered in the negative):