42.  Do you experience menstrual cramps?

____ no      ____ yes, mild      ____ yes, moderate      ____ yes, severe

43.  Have you had any problems with your period lately?  If yes, please specify:

44.  Have you ever had any of the following pregnancy outcomes?

Outcome                                                                                 Number                Date(s)

Miscarriage (pregnancy lasted less than 20 weeks)               ______             ________

Stillbirths (pregnancy lasted more than 20 weeks)                  ______            ________

Ectopic pregnancies (pregnancy not located in the uterus)     ______            ________

Voluntary abortions                                                                  ______            ________

45.  Please fill in the following information regarding all live births only:

 Birth            Date              Sex       Weight      Mult. Birth     Caesarean      Complications/

Order    MM/DD/YYYY      M/ F      lbs. ozs.      Yes/No          Yes/No          Malformations

   1     |        /       /           |            |                  |                   |                      |

   2     |        /       /           |            |                  |                   |                      |

   3     |        /       /           |            |                  |                   |                      |

   4     |        /       /           |            |                  |                   |                      |

   5     |        /       /           |            |                  |                   |                      |

46.  Please check whether or not you have ever used any of the following methods of birth control and specify the number of months you have used them:

Method       Yes/No     Duration in months        Method        Yes/No     Duration in months

Pill               ______     ______________          Rythm         ______     ______________

IUD              ______     ______________          Tubal          ______     ______________

Diaphragm  ______     ______________          Ligation       ______     ______________

Condom      ______     ______________          Vasectomy  ______     ______________

Foam           ______     ______________          Other          ______     ______________

47.  What method of birth control are you presently using and how many months have you been using it? _______________________________________________________

48. Please check below if you have ever taken any hormone for the following reasons:

Reason for use               Yes    |    No                     Reason for use                 Yes    |    No

To conceive                   ___          ___               Menstrual regulation        ___        ___

Morning after pill             ___        ___                To prevent miscarriage                    ___         ___

Other (please specify)   ___         ___

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