Questionnaire

INSTRUCTIONS:
1) For the questions whose answer is YES or NO, you should click on checkbox on the left:

2) For the questions whose answer is a NUMBER, you should type it on the textbox on the right:

3) For the questions whose answer is an OPTION, you should choose it from the list on the right:

4) Questions with no answer WILL NOT BE considered in the conclusions.

5) Please answer the questions below.

6) After providing the answers, press the "Conclusions" button at the end of the questionnaire.

GYNECOLOGICAL HISTORY:
How old is the woman? years old
At what age did the breasts start to develop? years old
At what age did the pubic hair start to develop? years old
At what age did the first menstruation come? years old
What is the periodicity of the menstruation? days
How many days of anticipation or delay does the menstruation have? days
When has the woman had her last menstruation? days ago
How long does the menstruation normally last? days

What is the normal amount of flow?

Does the woman present menstrual pains or cramps?
Have the menstrual pains or cramps gotten worse over the years?
Did the menstrual pains or cramps appear years after her first menstruation?
Does the woman have spontaneous lactation?
Does the woman have Premenstrual Syndrome - PMS?
Does the woman have any bleeding during ovulation?
Does the woman have frequent vaginal inflammations?

Please click on the main method(s) of contraception used?
- Pills
- IUD (intrauterine device)
- Others
- None

Discomfort or pain in any sexual position?
Cauterization of the uterine cervix?
Ovarian surgery?
Lack of menstruation not related to previous surgery?

OBSTETRIC HISTORY:
Has the woman been pregnant before?
Does the woman have children from previous relationships?
Does the man have children from previous relationships?
Has the woman experienced miscarriage?
Has the woman had infection due to miscarriage?
Has the woman undergone uterine curettage?
Has the woman had infection after uterine curettage?
Has the woman had reduction of vaginal flow after uterine curettage?
Has the woman had ectopic pregnancy?
Has the woman undergone ligation of one fallopian tube?
Has the woman undergone ligation of both fallopian tubes?
Has the woman undergone plastic surgery of the fallopian tubes?
Has the woman given birth to dead children?
Has the woman had bleeding after giving birth?

FEMALE MEDICAL HISTORY:
Has the woman experienced any weight variation?
Has this weight variation been greater than 30% of her normal weight?
Does the woman have intense physical activity?
Has the woman undergone abdominal surgery?
Has the woman undergone pelvic surgery?
Has the woman had pelvic infection?
Has the woman had ovarian inflammation?

Has the woman had any of the following diseases?
- Rubella (German measles)
- Urinary tract infections
- Frequent cystitis
- Tuberculosis
- Diabetes
- High blood pressure
- Liver diseases
- Kidney diseases

Has the woman experienced allergies?
Has the woman experienced visual alterations?
Has the woman had sexually transmitted diseases - STDs?

Which STD(s)?
- Gonorrhea
- Bartholin gland diseases
- Chlamydial infections
- Anaerobics
- Other STD

Has the woman had epilepsy?
Has the woman had headaches or migraines?
Has the woman had olfactory function alterations?
Has the woman had nauseous feelings or vomiting?
Has the woman had diarrhea or stomach disorders before or during the menstruation?
Does the woman use any of these substances?
Reserpine, phenotiazine, thioxanthene, butyrophenone, benzamine, diazepinic,
morphine, cocaine, heroine, marihuana, methadone, contraceptive hormones,
cimetidine, alphametildopa, verapamil, corticoid, thyroid hormone.

DATA OF INTEREST:
Has the woman undergone artificial insemination - AI?
Has the woman undergone gamete intrafallopian transfer - GIFT?
Has the woman undergone zygote intrafallopian transfer - ZIFT?
Has the woman become pregnant due to any of these treatments?
Does the woman have depression, anxiety or another emotional disorder?

SEXUAL HISTORY:
How many sexual relations does the couple have per month?
Has the couple experienced any change in their sexual behavior?
Does the couple have relations during the menstruation?
Does the couple practice anal intercourse?
Is intercourse painful?
Is there any bleeding during or after intercourse?
Does the couple use lubricants?
Does the woman use vaginal shower?
Does the man present lack of erection?
Does the man finish the intercourse too fast or feel pain?
Does the man present penile irritation?

HABITS:
Does the woman smoke?
Does the man smoke?
Is the woman alcoholic?
Is the man alcoholic?
Does the woman use drugs?
Does the man use drugs?
Does the man use tight underwear?

MALE MEDICAL HISTORY:
Has the man experienced any weight variation?
Has this weight variation been greater than 30% of his normal weight?
Does the man have intense physical activity?
Has the man undergone penile, testicular or inguinal surgery?
Has the man had testicular trauma?
Has the man had testicular inflammation?
Has the man had any sexually transmitted disease - STD?
Has the man had pus secretion together with the STD?
Has the man had kidney diseases?
Has the man had allergies?
Has the man experienced visual alterations?
Has the man had epilepsy?
Has the man had headaches or migraines?
Has the man had olfactory function alterations?
Has the man had any kind of tumor?
Has the man had varicocele?
Has the man had pain in the testicles?
Has the man had mumps after his adolescence?
Has the man had contact with toxic products and substances?
Has the man had any sperm alteration (low count, high dead ratio or bad formation)?
Has the man undergone vasectomy?
Does the man use any of these substances?
Colchichine, cimetidine, reserpine, alphametildopa, clonidine, verapamil,
ketoconazol, corticoid, propranolol, morphine, cocaine, heroine, marihuana.

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