49. Please check below whether or not you have ever experienced any of the following gynecologic problems:
Yes | No Yes | No
Excess. vaginal discharge ___ ___ Ovarian cysts ___ ___
Bleeding after intercourse ___ ___ Recurrent bladder infection ___ ___
Bleeding between periods ___ ___ Syphilis or gonorrhea ___ ___
Fallopian tube infection ___ ___ Herpes (genital) ___ ___
Pelvic infection ___ ___ Vaginal infection ___ ___
Endometriosis ___ ___ Premature labor ___ ___
Difficulties with urination ___ ___ Abnormal pap smear ___ ___
Problems with infertility ___ ___ Other (please specify) ___ ___
50. Please check below whether or not you have had any of the following gynecologic procedures:
Yes | No
D & C ___ ___
Cryotherapy (freeze) ___ ___
Bladder or kidney surgery ___ ___
Cervical cone ___ ___
Laser treatment ___ ___
Hysterectomy (removal of uterus) ___ ___
Oophorectomy (removal of ovary) ___ ___
Cautery ? hot or cold ___ ___
Pelvic cyst ___ ___
Irradiation (x-ray) ___ ___
Hysterogram (uterine x-ray) ___ ___
Other, please specify ___ ___ ___________________________
51. Have you ever had any benign or malignant tumors removed?
____ yes ____ no ____ unknown If yes, type and dates:
___________________________________________________________________
52. Please supply a list of all care providers and their addresses with regard to your gynecological history. Also include the hospitals you may have been admitted to, the dates or such hospitalization, and the injuries and/or conditions you were treated for.
If you do not know all of this information, do your best. Tax returns, cancelled checks, items in your medicine cabinet, and telephone books may be of great assistance.
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