for Lee’s Oriental Health Foods

Age you started menstruating _________________

If menopause has occurred, at what age? __________________

Length of cycle (e.g. 28 days) ________________

Regular or irregular period cycle? __________________________________

Describe any menstrual cramps you may have (mild, moderate, severe, etc.) _____________________________________________________________

Color of menstrual flow (anywhere from bright red to black) ____________

Odor of menstrual discharge? (mildly unpleasant, very strong, fishy, etc.)

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Any discharge between periods? Describe. __________________________

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Do you have children? ______ If so, how many? ____________

What months were they born? ___________________________________

If during the summer, did you have air conditioning on? _______________

Do you use birth control? ________What kind? _____________

Any miscarriages? _____ How many? _____________

Any other relevant information about your health?

_____________________________________________________________

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