Male Medical History Form - Dhcs
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1
2Name
Age
Date of Birth
Date
MALE MEDICAL HISTORY
This information is confidential and will be used by your medical provider to make sure you get proper care.
❏ Yes ❏ No Are you allergic to any medications? List here:
❏ Yes ❏ No Do you take any over the counter medicines, prescription medicines, vitamins, supplements, or home remedies?
List here:
❏ Yes ❏ No Do you have a usual source of primary care? If yes, who?
A. Family Medical History:
Provider notes:
Has anyone in your family (mother, father, brother, sister) ever had:
1. ❏ Heart attack/disease
5. ❏ High cholesterol
9. ❏ Mental illness
2. ❏ Stroke
6. ❏ Diabetes
10. ❏ Maternal DES exposure
3. ❏ Blood clot in legs/lungs
7. ❏ Alcohol or drug abuse
11. ❏ Cancer
4. ❏ High blood pressure
8. ❏ Birth defects/genetic
12. ❏ I do not know my family
problems
medical history
B. Personal Medical History:
1. Have YOU ever had problems with any of these? Check all that apply.
A. ❏ Heart disease
J. ❏ Anemia
R. ❏ Liver problems or
B. ❏ High blood pressure
K. ❏ Sickle cell disease
hepatitis
C. ❏ Stroke
L. ❏ Kidney/bladder problems
S. ❏ Gall bladder disease
D. ❏ Diabetes
M. ❏ Seizures or epilepsy
T. ❏ Eating disorder
E. ❏ High cholesterol
N. ❏ Depression
U. ❏ Cancer
F. ❏ Tuberculosis (TB)
O. ❏ Suicidal thoughts
Type: ______________
G. ❏ Asthma
P. ❏ Mental illness
V. ❏ Thyroid disease
H. ❏ Blood clot in legs/lungs
Q. ❏ Severe headaches or
W. ❏ Infertility
I. ❏ Bleed/bruise easily
migraines
2. ❏ Yes ❏ No Have you ever been hospitalized or had any surgery?
If yes, when and why? __________________________________________________
3. ❏ Yes ❏ No Have you ever had a transfusion or blood exposure?
4. ❏ Yes ❏ No Have you been immunized against rubella? ❏ I do not know
5. ❏ Yes ❏ No Have you been immunized against hepatitis B? ❏ I do not know
❏ I never had a genial exam
6. When was your last genital exam? _______________________
❏ Yes ❏ No Were you ever told there was any problem?
If yes, what? _____________________________
7. ❏ Yes ❏ No Have you ever had an HIV test?
Was it: ❏ Positive ❏ Negative?
If yes, when was your last one? ______________
C. Contraception History:
❏ I never had sex
1. How old were you when you first had intercourse?_____ years old
2. How important is it for you to avoid pregnancy now? ❏ Very
❏ Somewhat
❏ Not at all
3. What birth control methods have you and your partner(s) used in the past? ❏ None
A. ❏ Condoms/rubbers
F. ❏ IUD
J. ❏ Foam/film or jelly
B. ❏ Birth control pills
G. ❏ Implants under the skin
K. ❏ Withdrawal/pulling out
C. ❏ DepoProvera/shot
H. ❏ Diaphragm/cervical cap
L. ❏ Rhythm method
D. ❏ Patch
I. ❏ Tubal ligation/tubes tied
M. ❏ Vasectomy
E. ❏ NuvaRing (vaginal ring)
❏ None
4. What birth control are you and your partner(s) currently using? ____________________
5. ❏ Yes ❏ No
Are you happy with your method?
❏ Always
❏ Sometimes
❏ Never
6. How often do you use condoms?
7. ❏ Yes ❏ No
Have you ever used emergency contraception (morning after pill/Plan B)?
8. ❏ Yes ❏ No
❏ Unsure
Have you ever gotten anyone pregnant?
9. ❏ Yes ❏ No ❏ Maybe Are you and your partner planning to get pregnant in the next two years?
April 2008
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