Women’s Fertility History

Age at which menses began

Are your periods painful?

Yes

No

How many days does the pain last?

How many days do you normally bleed?

What color is the blood?

Light Red

Red

Dark Red

Purple

Brown

Black

How heavy is the bleeding?

Light

Normal

Heavy

Is there clotting?

Yes

No

Do you have premenstrual tension?

Yes

No

Does your face break out before or during your period?

Yes

No

Do you have premenstrual breast tenderness?

Yes

No

Do you bleed or spot between periods?

Yes

No

Are your menstrual cycles spaced irregularly?

Yes

No

How many days are there from one period to the next?

Date of last menstrual period?

Have your cycles changed since they began?

Yes

No

How have they changed?

Do you ovulate on your own?

Yes

No

On what day of your cycle?

Do your breasts get tender at/during ovulation?

Yes

No

Do you get premenstrual low back pain?

Yes

No

Do your bowel movements become loose at the beginning of your period?

Yes

No

Dr. Heidi Kao

Acupuncture and Chinese Medicine

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Women’s Fertility History

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Menstruation History