Reproductive Health Questions Page 2
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2Name: ___________________
Date: ___________________
Your Job and Hobbies.
What type of work do you do? __________________________________________
Do you work with pesticides, dry cleaning fluids, paint strippers, oven cleaners, ceramics,
solder, or welding at home or at work?
□ Yes
□ No
Do you work with radiation or x-rays?
□ Yes
□ No
Do you change cat litter boxes?
□ Yes
□ No
Your Diet and Nutrition.
Do you take a vitamin containing folic acid each day?
□ Yes
□ No
□ Don’t know
Do you eat cereal fortified with folic acid each day?
□ Yes
□ No
□ Don’t know
Name of cereal: ______________________
Do you eat raw or very rare meats or fish?
□ Yes
□ No
Do you eat unpasteurized dairy products?
□ Yes
□ No
Do you eat soft cheeses like feta, blue, brie, or queso fresco?
□ Yes
□ No
Your Sexual Practices.
Have you ever had a sexually-transmitted infection?
□ Yes
□ No
Have you had sex with more than one partner or has
your partner had sex with more than one partner?
□ Yes
□ No
Some women and some men use sex to get things they need.
Have you ever had to do this?
□ Yes
□ No
As far as you know, have you ever had sex with someone who
had HIV or AIDS or a sexually transmitted infection?
□ Yes
□ No
was a man who had sex with men?
□ Yes
□ No
used IV drugs or put drugs into their veins?
□ Yes
□ No
was a prostitute?
□ Yes
□ No
was a free bleeder or hemophiliac?
□ Yes
□ No
Has the use of alcohol or any other drug ever caused you to do
things sexually that you normally would not do?
□ Yes
□ No
Have you ever had a job that exposed you to blood or
other body fluids?
□ Yes
□ No
Do you prefer to have sex with men, women, or both?
□ Men
□ Women
□ Both
Georgia “Every Woman, Every Time” Preconception Care Toolkit
Funded by the Georgia Department of Community Health, Division of Public Health.
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