Date of Birth

MM

DD

YYYY

Childhood illness

Measles

Mumps

Rubella

Chickenpox

Rheumatic Fever

Polio

Immunizations and dates

Tetanus

Hepatitis

Influenza

Pneumonia

Chickenpox

MMR (Measles, Mumps, Rubella)

Do you drink alcohol?

Yes

No

Do you currently use recreational or street drugs?

Yes

No

Have you ever given yourself street drugs with a needle?

Yes

No

Are you sexually active?

Yes

No

Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?

Yes

No

Is stress a major problem for you?

Yes

No

Do you feel depressed?

Yes

No

Do you panic when stressed?

Yes

No

Do you have problems with eating or your appetite?

Yes

No

Do you cry frequently?

Yes

No

Have you ever seriously thought about hurting yourself?

Yes

No

Do you have trouble sleeping?

Yes

No

Have you ever been to a counselor?

Yes

No

Date of last menstruation

MM

DD

YYYY

Heavy periods, irregularity, spotting, pain, or discharge?

Yes

No

Any urinary tract, bladder, or kidney infections within the last year?

Yes

No

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.

Skin

Head/Neck

Ears

Nose

Throat

Lungs

Chest/Heart

Back

Intestinal

Bladder

Bowel

Circulation

Any recent changes in:

Weight

Energy level

Ability to sleep

Other pain/discomfort