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Blank No.30 Series II. Form B. 5.
11- Menstruation:
First menstruation at what age? And when thoroughly established?
at 15 estab. about a year

Present condition as regards menstruation? [menopause?]
(a) how frequent? irregular 24-38
(b) is it regular or not? formerly reg.
(c)amount? how many napkins?
(d)duration?
(e)pain or not? at what time as to the flow,
(f) is there any leucorrhoea (white)? character?
amount?
constant or occassional?
(g) have you pain either frequently or habitually in the head, small of the back? abdomen or limbs?
No.
(h) disease or trouble in uterus (womb) or other pelvic organs
(i) habit of bowels how often? reg.