Questionnaire

Reproductive
(Gynecology/ Female within Reproductive Age but not conceived/gotten pregnant)

Name: _______________________________________
Age: ___________ Civil status:
Religion: _________ __Single __Divorce/Separated
Height: __________ __Married
Weight: _________ __Widowed

I. Menarche:______________
1st day of LMP:___________
Menstruation: __Regular __Irregular __Dysmenorrhea (Check if present)
Fertility: __Fertile __Infertile
Medication use:_____________
Family history of gynecologic problems:_________________
Previous illness:_________________
Past gynecologic surgery/trauma:____________
Use of contraceptive:______________
Papsmear history: ____________

II.Urinary symptoms:
__Dysuria __Color of urine
__Urinary frequency __Consistency
__Oliguria __Anuria
__Urinary incontinence __Voiding irritation

III. Discharges:
Characteristic/Color: Odor:
__Milk-white to gray __Fish-like odor
__Thick, white, cheese like __Strong and putrid
__Frothy white __Others:_____________
__Grayish-green Pain (Lower Abdomen)
__Watery vaginal discharge __Flank pain
__Whitish urethral discharges __RLA
__Grayish-white __LLA
__Others:____________ Character of pain?____________
IV. Other signs and symptoms:
__Fever
__Vulvar reddening, burning or itching
__Vaginal irritation
__Urethritis
__Irregular vaginal bleeding
__Presence of pinpoint petechiae
__Presence of painful pinpoint vesicles
__Presence of lesions/chancre on the genitals/rectal
area
 Reproductive
(Male who are at reproductive age)

House number:____________________
Name:______________________________
Age:_________
Status: __Single
__Married, if married; indicate number of wives:____
number of children:____
__Widowed
Educational attainment:
__Elementary
__High School
__College
__None
Health Habits:
a.) Is there any cultural practices related to reproductive system? Specify_____________________
b.) Do you smoke? __Yes __No
If yes, how frequent? _______
How long? __________
c.) Do you drink alcohol? __Yes __No
If yes, describe your drinking habit: __Mild
__Moderate
__Excessive

1.Do you know of any hereditary illness in your family?

__Yes __No, if yes specify:_______________
2.Are you diagnosed of any previous illness?
__Yes __No, if yes what?________________
3.Do you take or maintain any medication?
__Yes __No, if yes enumerate: ___________
4.Are you circumcised?
__Yes __No, is yes when?_______________
5.Have you undergone any diagnostic procedures concerning your reproductive health?
__Yes __No specify:__________________
6.Do you notice any abnormal discharges?
__Yes __No, if yes describe:_____________
7.Do you have knowledge of TSE?
__Yes __No, if yes have you notice any abnormal painless lumps: __Yes __No
8.Do you exhibit urinary frequency?
__Yes __No
9.Do you feel any pain upon urination?
__Yes __No, if yes describe the pain score:_____
10. Do you do family planning?
__Yes __No, if yes: __Natural
__Artificial
What family planning?_______________

Reproductive
(For female who had been pregnant/current pregnant)
Name: ______________________
Age: __________________
Sex: __________________
Status:________________
Occupation: ________________

Female
Menarche:______________________
Cycle: _________________
Age of pregnancy: ________________
Amenorrhea: _______________
Dysmenorrhea:______________
Irregular menses: ______________
OB score: G____ T_____ P_____ A_____ L______ M_______
Fundic height:_____cm
FHT: __________
LMP: _________
Expected date of confinement: _________________

Lifestyle
Diet: _____________ (usual food intake)
ADL: _____________________________
Exercise: __________________________
Vitamins and supplements intake: _____________________
( )iron ( )vit. C ( )multivitamins ( )iodine
OTC drugs ____________ amount ____________ frequency _______________
Alcohol
Amount________________
Frequency ______________
Smoking
Amount _________________
Frequency _______________

History
Have you or your relative experienced any of the following?
( ) obesity
( ) hypertension usual BP reading ____________
( ) DM
 ( ) cardiac disease
( ) renal disease
( ) depression

Signs and symptoms during interpartum

A. Bleeding
Amount ( ) scanty ( ) excessive
Period (number if days)_____________
Color of blood ( ) bright red ( ) darkened
When? ( ) 1st trimester ( ) 2nd trimester ( ) 3rd trimester
B. Pain
Location of pain ______________________
Pain score (0-10) _________
Radiation of pain? Where? ____________________
Alleviation of pain _____________________
Precipitating factors of pain ___________________
C. Difficulty of breathing ( )
D. Dizziness ( )
E. Nausea and vomiting ( )
F. Edema _____ where? _______________ grade __________

Prenatal check up
How many times do you go for prenatal check up?
1st trimester ____________
2nd trimester ___________
3rd trimester ____________
Where do you go for prenatal check up? And also for delivery?
( ) Brgy. Health Center ( put 1 for prenatal)
( ) hospital ( put 2 for delivery)
( ) Birthing Clinics
( ) Hilots
( )Midwife

Type of delivery
( ) CS 1st time ______ 2nd time _______ 3rd time ________
( ) NSVD number of children? ________________
 Immunization
TT1 _____ TT3 _____
TT2 _____ TT4 _____ cevarex (CV) ______

Family planning
Is the family uses family planning ( ) yes ( )no
Which of the following family method do you use?
( ) natural ( ) artificial
____ calendar ____ condoms
____ BBT ____ IUD
____standard days ____ Depo
____ withdrawal ____ Vasectomy
____ Ligation
____ Pills

Diagnostic Procedures
Have you undergone any diagnostic procedures? ( ) yes ( ) no
If yes, what procedure? And when?
( ) UTZ
( ) Papsmear
( ) BSE
( ) pregnancy test HCG
( ) CXR
Have you been diagnosed to any reproductive disorders? By a physician? ( ) yes ( ) no
If yes, what disorder? _____________ When? _____________
And what medication did you take for that disorder?______________________
Maintenance? _________________