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Blank No. 16 B Series II. Form B. 5.

11 - Menstruation:
First menstruation at what age? and when thoroughtly established?
13 at once
[in margin]Before cessation[in margin]
Present condition as regards menstruation
a_ how frequent? once a month
b) is it regular or not? never exact about 4 to 5 weeks
c) amount? how many napkins? 3 days. never copius
5 napkins.
d) duration? 3 days
e) pain or not? at what time as to the flow,
slight, 1st day & day before.
f) is there any leucorrhoea (whites)? character? ---
amount? ----
constant or occasional? ---
g) have you pain either frequently or habitually in the
head, small of the back? abdomen or limbs?
Common headache in school.
always weak[?] back at menstruation. Abdomen from bowel trouble
nervous pain in bowels.
h) diseases or trouble in Uterus (womb) or other pelvic organs?
Once. 2 days. [?]n't lift herself up in bed. Got over it by
rest.
i) habit of bowels; how often? never move of themselves.
Has used syringe. Constipation.

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