Get Planned Parenthood PPMPF 149 2014
______________ Age: ______ Do you have any allergies? Ye s No Are you allergic to: ___________________ What was the first day of your last menstrual period? Date: ___________ Was it normal (timing, amount of bleeding)? Ye s My last period was: On time Ea rly The amount of bleeding was: Norma l la te x me dica tion ( No La te Lighte r He a vie r Does your period come every month? Yes No Do you have any problems with your period? Yes .
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