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Page 1:  · Age at left ovary removal Age at right ovary removal Number of live births Do you have IMPLANTS? a No (If Yes, circle R for Right or L for Left) Date: Date: Date: Date: Date:
Page 2:  · Age at left ovary removal Age at right ovary removal Number of live births Do you have IMPLANTS? a No (If Yes, circle R for Right or L for Left) Date: Date: Date: Date: Date:

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