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Blank No.36 Series II Form B. 5.
11- Menstruation:
First menstruation at what age? And when thoroughly established?
Between twelve and thirteen
Present condition as regards menstruation
(a)how frequent? Twenty-six days
(b)Is it regular or not? Two [to?] three days occassionally
(c)amount? how many napkins? six to eight
(d)duration? About five days
(e)pain or not? at what time as to the flow?
No pain except little dragging in the back.
(f)is there any leucorrhoea (white)? character?
No
Amount?
Constant or occasional?
(g)Have you pain either frequently or habitually in the head, small of the back? abdomen or limbs?
When standing on feet too much.
(h)disease or trouble in uterus (womb) or other pelvic organs?
None
(i)Habit of bowels; how often? loose - usually once a day sometimes twice a day