S M Partnered D WD

Name / Age / Occupation / Marital Status (Circle one) / Date

Describe any health concerns:

______

SYSTEMS: Since your last exam have you had: Any history of recreational drug uses?...... noyes

Any eye disease, injury, impaired sight...... noyesSex: abstinent active satisfactory unsatisfactory

Any ear disease, injury, impaired hearing...... noyesSexual orientation: Heterosexual Homosexual Bisexual

Any trouble with nose, sinuses, mouth, throat...... noyesWork______hours/day – Indoors Outdoors

Loss of consciousness/ Fainting Spells...... noyesDo you like your work?...... no yes

Convulsions...... noyesRecreation:

Paralysis...... noyesDo you participate in sports or have any hobbies

Dizziness...... noyes which give you relaxation at least 3 hrs/wk...... noyes

Frequent or severe headaches...... noyesTV ______hrs/day

Depression or anxiety...... noyesReading ______hrs/week

Hallucinations...... noyesVacations ______weeks/year

Enlarged glands or lumps...... noyesMEDICATIONS: List all medications, vitamins or supplements you are now

Enlarged thyroid or goiter...... noyestaking including over the counter medications, and include amount and

Skin changes or changes in moles...... noyesfrequency:

Chronic or frequent cough...... noyes

Chest pain or chest pressure...... noyes

Night sweats...... noyes

Shortness of breath...... noyes

Palpitation or fluttering heart...... noyes

Swelling of hands,feet or ankles...... noyes

Varicose veins...... noyes

Extreme tiredness or weakness...... noyes

Kidney diseases or stones...... noyes

Bladder disease...... noyes

Albumin, sugar, pus, etc. in urine...... noyes

Difficulty urinating...... noyes

Abnormal thirst...... noyes

Stomach trouble or ulcer...... noyes

Indigestion...... noyesHIV RISK:

Liver or gall bladder disease...... noyesHave you been intimate with prostitute or IV drug abusers?.....noyes

Jaundice or hepatitis...... noyesHave you had more than one sexual partner in

Colitis or other bowel disease...... noyesthe last year?...... noyes

Hemorrhoids or rectal bleeding...... noyesin the last five years?...... noyes

Constipation or diarrhea...... noyesHave you or your sexual partner had any transfusions

Has there been any recent change in: between 1978 and 1985?...... noyes

Your appetite or eating habits...... noyes

Your bowel action or stools...... noyes

Any unintentional weight loss...... noyesALLERGIES: Are you allergic to:

Exposure to tuberculosis or positive sign test...... noyesPenicillin or Sulfa...... noyes

Gonorrhea, syphilis, herpes or genital warts...... noyesAspirin, Codeine or Morphine...... noyes

Aching or swelling muscles or joints...... noyesMycins or other antibiotics...... noyes

FAMILY HISTORY: Since your last exam,any new medical Any other drug...... no yes

problemsin bloodrelatives?...... noyes Any foods (including eggs)...... noyes

HABITS: Exercise Regimen—type of activity, frequency and Adhesive tape...... no yes

duration: Tetanus or other vaccines...... no yes

INJURIES: Since your last exam have you had any:

Sleep well...... no yesBroken or cracked bones or dislocations...... noyes

Average hours of sleep______Sprains...... noyes

Bowels more regularly?...... noyesConcussions or head injury...... noyes

Diet well balanced?...... noyesKnocked unconscious...... noyes

Salt use: Light Moderate Much Hospitalizations...... noyes

Caffeinated beverage: ______cups per day – kind ______

Water: ______cups per dayWOMEN ONLY:

Menstrual History: Cycle:______days from start to start

Usual duration: ______days Heavy Medium Light

Pains or cramps: yes no Regular: yes no

Date of last period: ______Date of last pap smear: ______

Alcoholic beverages: Date of last mammogram:______

Amount______Frequency ______Type______Breast lumps, tenderness or discharge?...... noyes

Have you been treated for alcoholism ...... noyesAge at onset of menopause______if applicable

Have you used tobacco?...... noyes

How long?______When stopped?______IMMUNIZATIONS: Since the last examination, please circle:

How much per day? ______Tetanus German Measles (Rubella) Measles (Rubeola) Mumps Influenza

Type: Cigarette: Cigars Pipe Snuff Chewing tobacco Pneumovax Chicken Pox Zostavax (Shingles) Polio Hepatitis A Hepatitis B

Gardasil (HIPV)