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Blank No. 28 Series II. Form B. 5.
11- Menstruation:
First menstruation at what age? and when thoroughly established?
13.5. [At once though suffered?]
Present condition as regards menstruation
a) how frequent? irregular [1 in?] 5 mo. 2-3-5 mo
b) is it regular or not? [twice everything slowly?]
c)amount? how many napkins?
[now less and less?], in youth 5. now 2
d)duration? 5
e)pain or not? at what time as to the flow,
Pain. Due to [cloth?] as first
After 1st child's birth no pain
f)is there any leucorrhoea (white)? character?
at beginning of change of life
amount?
constant or occasional?

g)have you pain either frequently or habitually in the head, small of the back? abdomen or limbs?
overwork brings pain in back of neck

h)disease or trouble in uterus (womb) or other pelvic organs
[lacerated?] at birth of child due to rapid birth. never been [at luck?], overheated climbing stairs [incessantly?], ulceration [and?] uterus [lasted?] a year, [electricity?], [real?] applications.

i)habit of bowels; how often?
regular