RECREATION: Yes No Unknown Participate in sports or hobbies 3 hours a week. . Watch TV (hours per day). ..... Read (hours per week) ....... Vacations (weeks per year)... 4s Never } : 2 3. More REPRODUCTION. AND FAMILY: Problems* No Preblems Ability to have children Birth defects or deformations in children or arandchildren. q . ? *Explain: WOMEN ONLY: Menstrual History: Age at onset Regu lar Yes 12 or younger No Cycle {start to star t) Duration of days F low Heavy Pains or cramps 12 or older 28 days or less S or less Medium Yes Light No eee 28 days or more 5 or more Pregnancies: Number of children... Number of stillbirths. . Number of premature births . Number of cesarean sections. * ses 7} # @ 2 3 4 5 or more @ ..... Number of miscarriages . * © e # @# # @ Any complications with any pregnancy . 10 Yes No Unknow