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Action Form: Permanent Birth Control: The Facts

If you had a medical diagnosis, how difficult was it to get a correct one?
Don't Know Easy Difficult Impossible

What kind of experience have you had with the medical profession?
Don't Know Bad Good Excellent

If you used a alternative practitioner, what kind of experience did you have?
Don't Know Bad Good Excellent

What did you find worked for you?
Stress Reduction Vitamins Herbs Diet Change
Prescription Drugs Exercise Time-Off Body Work

Who would you like to be informed about this subject?
Medical Associations Government Regulatory Agencies Elected Representatives Drug and Supplement Manufacturing Companies

What following conditions do you think apply to you. (Check anything that might apply)

Check off any of the following therapies or procedures you use.

abdominal surgery
abdominal pain abnormal uterine bleeding burning
cramping dry vagina early estrogen deficiency
estrogen deficiency excessive growth of breast tissue gastritis
heavier periods heavier menstrual periods heavier bleeding
heavy lifting increased menstrual pain irritable bowel syndrome
laparoscopic sterilization loss of libido lowered hormone levels
major abdominal surgery menstrual pain menstrual complications
pain in the low back painful periods premature menopause
prone to bleed recurrent abdominal pain scars
small scars therapeutic abortion tubal reconstructions
tubal pregnancy unwanted pregnancy urinary problems

Make your imput count. The information you submit will be compliled with all other submissions and used to activate for positive change in women's health.

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