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What type of contraceptive did you use before?
type of contraceptive
Are there any side effects?
Side effect
What is your nationality? What is your race ?
Nationality & Race
What is your address and telephone number ?
Address & telephone
How long did you use this method of contraceptive?
Length of time using this
method
Are you married?
Marital status
What is your occupational?
Occupation
What’s your problem? / what’s your chief complaint?
Chief complaint
When did the complaint start?
Date and time onset
Where is the location? Or show me where the location is?
Specific location
How does the pain feel or what is the pain like?
Type of pain or discomfort
When did you get the first time period?
Age at menarche
How many days usually it happened ?
Duration
When did you have your last menstrual period?
Last menstrual period
Is there any problem during period like dysmenorrhoea or premenstrual syndrome?
Dysmenorrhoea
How many times have you been pragnant? How many children do you have?
Gravida/ Para
