Initial History And Examination Form - Male - Family Planning Program
ADVERTISEMENT
1
2Family Planning Program: Initial History and Examination – Male
Name:
Date of Birth:
Date of Visit:
The information you give us will be kept confidential and only disclosed to others with your written consent or as required by law.
MEDICAL HISTORY (
)
Yourself
FAMILY HISTORY
I am adopted.
Drug/medication Allergies (
)
specify
(Please enter any information you have on your
biological family; otherwise proceed to LIFE STYLE and MEDICAL HISTORY)
Other Allergies
(specify)
Information about blood relatives only (
Which of the following do you take regularly:
mother, father,
(please list)
)
Prescriptions
Over the Counter
Street Drugs
siblings, grandparents
Indicate if a member of your family has any of the
following, (
):
relationship and age of onset
Heart Disease/Stroke
Have you ever had surgery or been hospitalized?
High Blood Pressure
No
Yes (
Please list reasons)
Cancer (
breast, ovarian, colon, prostate, other)
Diabetes
Headaches
Thyroid problems
Heart Disease
Other chronic conditions
High Blood Pressure
If you were born between 1940 and 1970, did your
High Cholesterol or Triglycerides
(Circle)
mother take medication (DES) to keep from losing the
Thyroid Disease
pregnancy?
NA
Yes
No
Do not know
Asthma
Kidney Problems
LIFE STYLE HISTORY
What concerns do you have about your weight?
Hepatitis
None
Overweight
Other liver disease
Underweight
Other: _________________
Diabetes
What kind of tobacco do you use?
Other chronic diseases?
None
Smokeless: Daily _____ Weekly _____
Cigarettes: #/day____ # yrs. _____
Have you had your immunizations (shots), especially
Rubella?
Yes
No
Do not know
UROLOGICAL HISTORY Have you ever had any
Hepatitis?
Yes
No
Do not know
of the following?
(Please √ all that apply)
Abnormality of the penis
CONTRACEPTIVE HISTORY
(describe)
What method of birth control have you used?
Discharge from the penis
(describe)
Condoms
Vasectomy
None
Are you having a problem with this now?
Problems?
No
Yes ____________________
Sores on the penis
(describe)
Have you ever caused a pregnancy?
Are you having a problem with these now?
No
Never tried
Unsure
Sores or lumps on the scrotum?
(describe)
Yes If yes: Number of times:_______
Are you having a problem with these now?
What method(s) of birth control are you using now?
Date first noticed:
Condoms
Vasectomy
Do you do Testicular Self Exam?
No
Yes
None
Partner’s
What Sexually Transmitted Diseases have you had?
When did you last use this method? __________
)
(Please √ all that apply and give date of treatment
Have you had sex without birth control or condoms
Chlamydia
Gonorrhea
________
___________
in the last month?
No
Yes
_________
Herpes
Syphilis
___________
_____________
(dates)
Trich
Warts
___________
______________
What methods of birth control does your partner use?
Hepatitis (type
HIV
___)
________________
(check all that apply)
Other (Please specify)
:____________________________
None
Unsure
Pills
Shots (Depo)
Treatment:
__________________________________________
Patch
Vaginal Ring
Implant
IUD
Female Condom
Vaginal spermicide
CDPHE-WH • REVISED 02/09
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical