Question Index: Reproductive History
| Questions
|
Year(s) Asked on Long Forms (Click on year to view PDF of questionnaire.) |
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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Age at menarche | x | |||||||||||||
| Patern of menstrual cycles at ages 18-22 | x | |||||||||||||
| Pattern of menstrual cycles missed (menarche to age 22) | x | |||||||||||||
| Menstrual cycle regularity (age 20-35) | x | |||||||||||||
| Had a pregnancy lasting > 6 months? How many? | x | |||||||||||||
| Had a pregnancy lasting > 6 months in the last 2 years? Delivery date? | x | x | x | |||||||||||
| Age at first pregnancy | x | |||||||||||||
| Any stillbirths? If so, how many? | x | |||||||||||||
| Parity | x | x | x | x | x | x | ||||||||
| Number of children and ages | x | x | ||||||||||||
| Tried to become pregnant for > 2 years without success? | x | |||||||||||||
| - If yes, was cause found in you, husband, not found, or not investigated? | x | |||||||||||||
| Use of clomid to induce ovulation (total months used, age first used) | x | |||||||||||||
| Ever treated with DES during pregnancy? | x | |||||||||||||
| Have you reached menopause? | x | x | x | x | x | x | x | x | x | x | x | x | x | x |
| Age at menopause | x | x | x | x | x | x | x | x | x | x | x | x | x | ? |
| Type of menopause (e.g. natural, radiation or surgical, if so number of ovaries removed) | x | x | x | x | x | x | x | x | x | x | x | x | x | ? |
| Uterus removed? | x | x | x | x | x | x | x | x | x | x | x | x | ||
| Ovaries removed? How many? | x | x | x | x | x | x | x | x | x | x | x | x | ||
| - How many ovaries do you still have | x | x | x | x | x | |||||||||
| Ever had a tubal ligation? | x | x | ||||||||||||
| Current contraceptive use (OC, rhythm, diaphragm, condom, IUD, foam/jelly, tubal ligation, vasectomy, other)? | x | x | x | x | ||||||||||
| Past contraceptive use? (Or previous 2 years) | x | x | x | x | ||||||||||
| Oral Contraceptive Timeline: Intervals of use and Reason for stopping | x | x | x | |||||||||||
| Duration of OC use | x | x | x | x | ||||||||||
| Age at first OC use | x | |||||||||||||
| Total months breast fed children | x | |||||||||||||
| Birth weight of heaviest child | x | |||||||||||||
| Age at first delivery > 9.5 lbs. | x | |||||||||||||
| Age at birth of heaviest child | x | |||||||||||||
| Each year in which you gave birth | x | |||||||||||||
| Regarding your infancy: Birthweight? Were you breast fed? Full-term? 2+ weeks premature? Twin, triplet? | x | |||||||||||||
| Use of Postmenopausal Hormones including: | x | x | x | x | x | x | x | x | x | x | ||||
| - Duration of use | x | x | x | x | x | x | x | x | x | x | ||||
| - Currently using? | x | x | x | x | x | x | x | x | x | |||||
| - Type? | x | x | x | x | x | x | x | x | x | |||||
| - Dose of preparation | x | x | x | x | x | x | x | x | ||||||
| - Route of administration | x | x | x | |||||||||||
| If Premarin, what dose? Daily or cyclically? | x | x | x | x | x | x | x | x | x | x | ||||
| If Progesterone, what dose? | x | x | x | x | x | x | x | x | ||||||
| Pattern of hormone use (oral, patch, progesterone) | x | x | x | x | x | x | x | x | ||||||
| Currently using any of these meds for osteoporosis or other reason (HRT, Evista, Fosamax, etc.) How many months during last 2 years? | x | x | x | |||||||||||
| Have you regularly used any over the counter preparations ("alternative," "herbal," "natural," or "soy-based") for HRT or to treat postmenopausal symptoms? (last 2 years, # months, type) | x | x | ||||||||||||
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