Women’s Medical History
No. of Ectopic Pregnancies _____ Other:_____ No. of Living Children _____ ... Weight gain/loss Yes No Persistent Cough Yes No Joint pain Yes No. Loss of appetite Yes No Shortness of Breath Yes No Chronic Back pain Yes No ... REVIEW OF SYMPTOMS (check if you currently have any of the following symptoms) WOMEN’S MEDICAL HISTORY. ................
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