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Patient's questionnare
 
 
 
Age :
   
 
 
Marital status :
   
IF married since when ?
   
 
 
 
Menstrual History 

Days of flow :
Amount (Heavy,normal.light) :
Length between periods:
 
 
 
 
previous miscarriages ?
   
Birth control method ?
   
 
 
 
* Have you ever been pregnant?
   
* Any pregnancy complications:
   
 
Patient's file