Adult Health History Form Page 2
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411. For Men:
Do you examine your testicles regularly?
YES ____ NO ____
What is your method of pregnancy prevention? ____________________________________
How do you protect yourself against sexually transmitted diseases? ___________________
12. For Women:
Do you examine your breasts each month?
YES ____ NO ____
Have you ever uses oral contraceptives /birth control pills?
YES ____ NO ____
# of pregnancies? _____
# of children? _____
Have you ever used an IUD (Intrauterine Device)?
YES ____ NO ____
What is your method of pregnancy prevention? ___________________________________
How do you protect yourself against Sexually Transmitted Diseases? __________________
Have you completed your menopause?
Age:______
YES ____ NO ____
Do you use hormone replacement therapy?
YES ____ NO ____
HEALTH PROBLEMS
13. Have you ever had an allergic reaction or side effect to any medicines?
YES ____ NO ____
Name(s) _______________________________________________________________
14. Have you ever had any other allergic reactions?
YES ____ NO ____
(Bee sting, asthma, severe poison ivy, specific food, injections)
Explain ______________________________________________________________________
15. Have you ever been hospitalized?
YES ____ NO ____
Please list all. (Medical and surgical, biopsies, fractures, obstetric/gynecologic and psychiatric)
Nature of Problem
Date
City & State
Hospital
16. Please check previous box if you had the condition or problem in the past.
Check the now box if you currently have any of the following.
Previous Now
Previous
Now
Glaucoma
Seasonal Allergy/Hay Fever
Thyroid problems
Alcoholism
Increased cholesterol
Bleeding Tendency
Diabetes
Polio
Lung problems
Rheumatic Fever
Abnormal chest x-ray
Scarlet Fever
Abnormal cardiogram-EKG
Sinus or ear infection
Heart Murmur
Tuberculosis
High Blood Pressure
Pneumonia or Bronchitis
Heart problems
Syphilis
Stroke
Gonorrhea
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Parent category: Medical