Family Planning Annual Health History Form Page 2
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1
2Have you been a victim of Human Trafficking by being forced into sexual slavery, forced labor, or been forced to participate in sexual
activity for money?
Yes
No
Blood Transfusion History
Have you ever had a blood transfusion?
Yes
No If so, when? ________________________________________________
Female and Male History of Infections
When
Treated
When
Treated
Genital Warts
Yes
No
Syphillis
Yes
No
HIV/AIDS
Yes
No
Chlamydia
Yes
No
Trichomonas
Yes
No
Herpes
Yes
No
Gonorrhea
Yes
No
Other:
Yes
No
LSCC Family Planning Health History Form, Revised September 2014
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