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