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How frequently do your periods come?
How long do your periods last?
When did your last period start?
How would you describe the amount of your periods?
What is the colour of your period?
Do you have blood clots during your period?
Do you have white discharge between periods?
If yes, what is the nature?
Do you experience cramping with your periods?
If yes, when during your cycles do you have pain (check all that apply)
How would you describe the cramps?
Do you have other symptoms with your periods?
If yes, when during your cycles do you have these symptoms (check all that apply)
Do you bleed or spot between periods?
Have you ever had any of the following infections involving any part of the reproductive system?
If yes, what treatment did you receive and when?
Have you ever used contraception in the past?
If yes, which type of contraception ?
How long have you and your partner been attempting to achieve pregnancy?
Have you been treated for infertility previously?
What was the cause of infertility?
Have you ever attempted in vitro fertilization (IVF)?
If yes, please specify
Have you had a miscarriage before ?
If yes, please specify when
Do you have or have you ever had any of the following:
Do you consume meat or follow a vegetarian/vegan diet?
How many time per week do you consume meat, if so, do you consume red meat, chicken or fish?
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