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Blank No.35 Series II Form B. 5.
11- Menstruation:
First menstruation at what age? And when thoroughly established?
14.5, at once.

Present condition as regards menstruation. Change of life
(a)how frequent? month
(b)is it regular or not? regular
(c)amount? how many napkins?
excessive
(d)duration? 5
(e)pain or not? pain. At what time as to the flow,
(f)is there any leucorrhoea (white)? character? slight
Amount?
Constant or occassion?
(g)have you pain either frequently or habitually in the head, small of the back? abdomen or limbs?
(h) Disease or trouble in uterus (womb) or other pelvic organs? None
(i) habit of bowels; how often? Once in 2 days