Reproductive History Questionnaire

Year 1 Reproductive History Questionnaire

The following questions ask about your reproductive system. We are very interested in this information so that we can understand more about women's reproductive lives and their health. Some of the questions ask you to give ages when certain things happened. If you're not sure about the exact age, please give your best guess. Please be assured that all answers will remain confidential.

Section 1: Menstruation and Menopause

1. How old were you when you had your first menstrual period (menses)?

2. During most of your life, were your periods regular; that is, did they occur about once a month? (Do not include any time when you were pregnant or taking birth control pills.)
	not regular (skip to question 3) regular sometimes regular; sometimes irregular

	2.1 How old were you when your periods FIRST became regular? (Your best guess)

	2.2 How often did you have your cycle?	Every days

3. How old were you when you LAST had regular menstrual bleeding (a period)? (Your best guess. If you are still having regular bleeding or periods, enter your current age.)
	years old

4. Between the time you had your first period and your last period, did you ever stop having any periods for at least 12 consecutive months? (Do not consider times when you were pregnant or breast feeding.)
	no (skip to question 5) yes

	4.1 Between your first menstrual period and your last, all together, about how long did you go without having your period? Again, do not include times you were pregnant or breast feeding.)

5. How old were you when you last had any menstrual bleeding? (If you are still having menstrual bleeding or periods, enter your current age.)
	years of age

6. Have you ever had menopausal symptoms such as hot flashes, night sweats, mood swings, etc.? (Your best guess)
	no (skip to question 7) yes

	6.1 How old were you when you first had symptoms such as hot flashes or night sweats? Your best guess	years old

	6.2 How old were you when you last had symptoms such as hot flashes or night sweats? (If you are still having these symptoms, enter your current age.)	years old

Section 2: Pregnancy and Family Planning

7. Have you ever been pregnant?
	no (skip to question 8) yes

7.1 How many times have you been pregnant?

7.2 Did you ever have a pregnancy that lasted at least 6 months?

no (skip to question 8)
yes

7.3 How many of these pregnancies did you have?

7.4 How old were you at the end of the first of these pregnancies?

	7.5 How old were you at the end of the last of these pregnancies?

7.6 Did you breastfeed or nurse any children for at least one month?

no yes

7.7 How many children did you breastfeed?

7.8 How old were you when you first breastfed a child?

7.9 How old were you when you last breastfed a child?

	7.10 Thinking about all the children you breastfed, how many months total did you breastfeed? (Your best guess.)

8. Have you ever tried to become pregnant for more than 1 year without becoming pregnant?
	no (skip to question 9) yes

	8.1 Did you visit a doctor or clinic because you didn't get pregnant?	no (skip to question 9) yes

	8.2 Was a reason found for why you did not become pregnant?	no (skip to question 9) don't know (skip to question 9) yes

8.3 What was the reason you did not become pregnant? Mark all that apply.
	Problem with hormones or ovulation (producing eggs) Problems with fallopian tubes or uterus Endometriosis	Problem with my partner Don't know Other (specify)

For these next questions, please mark "none" if they do not apply to you.

9. How many live births have you had?

10. How many still births (from a pregnancy lasting 6 months or more) have you had?

11. How many spontaneous miscarriages?

12. How many tubal (ectopic) pregnancies?

Section 3: Surgeries and Procedures

13. Did you ever have an operation to have one or both of your ovaries taken out?
	no (skip to question 14) yes, one was taken out yes, both were taken out yes, unknown number taken out yes, part of an ovary was taken out don't know

	13.1 How old were you when you had your last operation to remove an ovary/ovaries?

14. did you ever have an operation to have your tubes tied to prevent pregnancy?
	no (skip to question 15) yes

	14.1 How old were you when you had your tubes tied?

15. Have you had any of the following procedures? (Please mark all that apply)
	needle aspiration (when a doctor/radiologist puts a needle into a lump in your breast and withdraws fluid or material) breast biopsy (when a doctor removes part or all of a breast lump to check for cancer) breast augmentation (breast enlargement) breast reduction any other breast surgery (specify)

	15.1 If yes to breast augmentation, how old were you when procedure(s) was performed?	years old

	15.2 What type of breast implant did you receive?

		silicone or silicone gel-filled saline other (specify) don't know

Section 4. Gynecologic Examination

16. Have you ever had a gynecological examination?
	no (skip to question 17) yes

	16.1 Date of most recent gynecological exam:	(ex: 02/04/1999)

	16.2 Findings of most recent gynecological examination:	negative positive suspicious

	16.3 Date of most recent pap spear:	(ex: 02/04/1999)

	16.4 Findings of most recent pap smear:	negative positive suspicious

	16.5 If you had a suspicious or positive pap smear, what was the date of the definitive procedure? (biopsy, sonogram, etc.)	(ex: 02/04/1999)

	16.5 If you had a suspicious or positive pap smear, please specify the definitive diagnosis:

Section 5: Breast Health

17. Have you ever had a breast examination by a medical professional?
	no (skip to question 18) yes

	If yes, most recent exam date:	(ex: 02/04/1999)

	17.1 What was the finding of the most recent examination?	negative positive suspicious

18. Have you ever had a mammogram?
	no (skip to Family History Questionnaire) yes

	If yes, most recent mammogram date:	(ex: 02/04/1999)

	18.1 What was the finding of the most recent mammogram?	negative positive suspicious

19. If breast examination or mammogram findings were suspicious, what was the date of the confirmatory biopsy? (approximately). If not applicable, skip to Family History Questionnaire.
	(ex: 02/04/1999)

20. If breast examination or mammogram findings were suspicious, what was the result of the confirmatory biopsy?
	Atypical Hyperplasia Proliferative Disease with Atypia Nonproliferative Disease Fibroadenoma Other Benign Breast Disease	Lobular Carcinoma in Situ Ductal Carcinoma in Situ Invasive Carcinoma Other (please specify) Don't know

10. How many still births (from a pregnancy lasting 6 months or more) have you had?