1 - ESDS
1 - ESDS
1 - ESDS
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W241WH MWQ34PWH<br />
Oldyoumldhe hava the apmtbrv<br />
A9 ●hosptil inpatiant,staying<br />
overnightor bnger ............ .. .....<br />
Asa ho~til oui$,tint<br />
Atyotulhh doctm%auqery<br />
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Or was ii cwiiad out aomwhem<br />
ok . ... .. ................................ .. . ..<br />
Refurnd . ......... .. .... . . ........ .<br />
Mining ................... .. ....... . ..........<br />
Wlwt mmm and year was tha opwation?<br />
own Husbmd’sl<br />
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Pmtl19ts<br />
operation<br />
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MV4Q361MH f#WQS6PMH MWQS61YR MWQ36PYR Own Husband’al<br />
Opm-aticil pm’tnal-s<br />
Opwath<br />
Entarmonth .. ............. ...... .. . .<br />
Enteryear ........................... . ....<br />
*36 ‘Ms dtiwr youror yourhtimi’dpartrws opwatbn lass<br />
than 2 y.3ama@?<br />
Yas ..... . ......... .................. .. . ......... ....... ... ................<br />
No ...... ................................... . . ... .... ....... .. ...... .... [q<br />
%fusod ........................... ........ ......... ................. ..... [1]<br />
MY’4Q37 VWkh of ttw falhwdngmathod(s)of pmwnting ptngnancy,if any,<br />
were YOUand your husbandIMIMUyusingInm’mdiataly bcfomthat?<br />
If ymuhad no SUIMI rahtianship, ring .._-..__<br />
If m IrNthOd U18d ●t all, Ilng ._.._— ______<br />
If YOUwm p+mgnmt,ting ___________<br />
If Udtlg ma a mom mathods, Iing all the<br />
ntmhra that ●pply<br />
wfthdmwal ................................ . . . . .. ...... . ..... ......<br />
Sh~ttVomdom .................................................................<br />
Safa pefbdhhythmmdlmd ... .. ... ... ...... .. ..... ........<br />
Ca#dlaphmgm ..<br />
Calltrarapdvosponge........ . ...................... ... ....... .<br />
Pllk minipill(progostamnoniy) ... ...... . .... ................. .<br />
Pllt cambinmdF41(includingmulti-ptmsicpill) .. ...... .......<br />
PIN notsum t minior Cemt.kmd<br />
Pleau WtiO the brand m b@OW..--.----—<br />
IuokaWt-Ul-m ** .... ..... .. ...... .... ........<br />
FoamdgcWswaya/p,rnriaa (apmmicides)<br />
Goingwithaulswiual intafmu= to avoid pregnancy .<br />
Injeclians .. .... ........... .... . .... .. . . ....<br />
Anothermethod<br />
Refuasd ... .. ...... . ...... . .... .... ........<br />
Plea- W* ib. - IMOw ..—.-———— ______<br />
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