FEMM health intake form Please fill out this form and hit submit. Name: Email: Date: Street address: Phone number: Ethnicity: Languages spoken: Occupation: Marital status: Reason for learning FEMM: How did you hear about FEMM: Physician (&phone number): OB/GYN physician (&phone number): Age when menstrual periods began: Date of last menstrual period: How long is your typical cycle (period to period): How long is your typical period (bleeding): Is bleeding heavy, moderate, or light: Have you ever experienced excessive bleeding? If yes, describe: How painful are your worst periods: Any bleeding between periods: Do you take medications with your periods? If yes, specify type: Have you ever used hormonal contraception (includes most IUDs): Yes No If yes, specify types, dates of use, and if problems were encountered: If yes, specify if used for medical reasons, and for what condition: Please check any symptoms that are present before onset of period: Irritability Bloating Breast tenderness Mood swings Depression Fatigue Headache Insomnia Food cravings Weight gain Other Average duration of symptoms: Severity of symptoms: Do you have persistent low mood: Do you have excessive anxiety: Have you ever had an eating disorder? If yes, explain: Do you have difficulty sleeping: Do you use sleeping aides? If yes, specify type: Have you ever had a vaginal or urinary tract infection? If yes, specify type and frequency: Have you ever had an STI? If yes, specify type and treatment: Date of last STI screening: Date of last PAP smear: Do you have a history of abnormal PAP smear? If yes, describe: Pregnancy 1 (Include date of birth, weeks at birth, weight, sex of baby, type of delivery, and if there are other relevant comments): Pregnancy 2 (Include date of birth, weeks at birth, weight, sex of baby, type of delivery, and if there are other relevant comments): Pregnancy 3 (Include date of birth, weeks at birth, weight, sex of baby, type of delivery, and if there are other relevant comments): Pregnancy 4 (Include date of birth, weeks at birth, weight, sex of baby, type of delivery, and if there are other relevant comments):New Field: Pregnancy 5 (Include date of birth, weeks at birth, weight, sex of baby, type of delivery, and if there are other relevant comments): How many total pregnancies have you had? How many living children do you have: How many total vaginal deliveries have you had: How many total caesarian sections have you had: How many spontaneous miscarriages have you had: How many induced abortions have you had: Describe any series problem with pregnancies: Are you currently breastfeeding: Do you want children in the future: Have you been trying to conceive and for how long: Have you had fertility treatment? If yes specify types and dates: Have you had any surgeries or hospitalizations? If yes, specify reasons and dates: Do you have any allergies? Include food, medicine, seasonal, etc.: Current medications (include vitamins, supplements, herbs, etc.): Do you drink alcohol? If yes, how often: Do you smoke? If yes, specify packs per day and length of time smoking: Do you drink caffeine? If yes, how often: Do you use recreational drugs? If yes, specify: Please tell us what your typical exercise is like and how often it's done: By singing below, I give consent for my health information to be used anonymously for education and research purposes of the FEMM program. I have the right to withdraw my consent at any time. I consent to Hannah sharing my information with FEMM (mandatory for this course) I consent to FEMM using my information for research anonymously. I understand that this class will provide me with information about FEMM and the way that I use this information is my own personal responsibility and Hannah Ransom will not be held liable for any failure of the method. Check here to submit a virutal signature.