33.  Please fill in the following information regarding your mother?s pregnancy history:

                                                                                                Number during which DES         
Pregnancy Outcomes                   Total Number                        was given (including you)
Miscarriages                                    ________                                        ________
Live born females                            ________                                        ________
Live born males                               ________                                        ________

34.  Was your mother ever hospitalized for illness or surgery?
___ yes    ___ no    ___ unknown      If yes, please specify:
________________________________________________________________

35.  Is there a history of cancer in your family? ___ yes    ___ no    If yes, please specify: Relative who had cancer                  Type of cancer                                    Age
________________________________________________________________

36.  Name and address of current treating gynecologist:
________________________________________________________________

37.  Who told you that you may have been exposed to DES?
____ your family doctor      ____ your gynecologist      ____ your mother
____ other, please specify: ___________________________________________

38.  Please state when and the name and address of the doctor who told you that DES was the cause of your problems:
________________________________________________________________

39.  At what are did your periods begin? _______ years of age

40.  What is the usual length of your menstrual cycle starting with the first day of one period and ending with the first day of the next? _______ days

41.  What is the average length of your menstrual flow? _______ days