| What was your age when you were diagnosed?: |
|
| Have you ever used a product such as KY Jelly? (Or another brand): |
|
| Did you ever use a douche? (Such as Summer’s Eve): |
|
| Have you had any yeast infections?: |
|
| Have you had any Urinary Tract Infections?: |
|
| Did you/ Do you swim on a regular basis?: |
|
| Where did you/ do you swim most?: |
|
|
|
| After you swam, did you leave your bathing suit on for very long?: |
|
| Did you/ Do you use a hot tub?: |
|
| Did you/ Do you take baths?: |
|
| If you took baths, did you put in oils?: |
|
| Did you put in bubble bath?: |
|
| What has been your primary method of birth control?: |
|
| Do you have children?: |
|
| How many pregnancies have you had?: |
|
| Do you (or have you) used hormone replacement therapy?: |
|
| Did anyone else in your family have OVCA?: |
|
| Did you have your tubes tied (tubal ligation)?: |
|
| Have you ever taken fertility drugs?: |
|
| Has your husband had a vasectomy?: |
|
| Do you eat organic meat on a regular basis?: |
|
| Do you eat/drink organic dairy on a regular basis?: |
|
| Do you live near industry?: |
|
| Before diagnosis, how long would you say you had “digestive type” issues?: |
|
| Throughout your lifetime, have you experienced problems with constipation?: |
|
| Throughout your lifetime, would you say that you have experienced problems with allergies?: |
|
| Was powder (of any sort) ever used on you as a child?: |
|
| Did you (do you) use tampons?: |
|
| Did you empty your bladder after intercourse?: |
|
| Do (Did) you spray your underwear with perfume?: |
|
| Type of underwear you have mainly worn throughout your life? |
|
| Did you usually wear thongs?: |
|
| Do you put scented soaps or sachets in your drawers?: |
|
| Do you use scented dryer sheets?: |
|
| Do you use scented detergents?: |
|
| How many sexual partners would you say you’ve had over your lifetime?: |
|
| At what age was your first sexual experience?: |
|
| At what age was your first sexual experience?: |
|
| Do (Did) you eat a lot of “junk” food ie. Chips, cookies, donuts?: |
|
| Do (Did) you eat a lot of refined sugar ie. (Candy)?: |
|
| Do you usually drink bottled water or tap water?: |
|
| Did you have endometriosis?: |
|
| Did you have fibroids?: |
|
| Your Name: |
|
|
|
| Your Age: |
|
| Your e-mail: |
|
| |