ALLERGIES (drugs, foods, latex) REACTION
Any changes in your period: _____________________________________________________________
Do you have sexual intercourse? Yes No
If yes, how do you prevent pregnancy? _________________________________________
If yes, do you have/have you had a new sexual partner since your last exam? : Yes No
Medical Problems (changes since last visit): ________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
Surgeries (changes since last visit, include surgeon’s name and date): _____________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Major Changes in your life: ______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Tobacco/Cigarettes Use: Never Quit (date)__________
Current smoker ____packs/day, X ____yrs
Alcohol Use: No Yes
# ______ drinks per week ( beer wine liquor)
Is alcohol use a concern for you or others?
Yes No
Drug Use: No Yes
If so, what drug(s)_____________________
Exercise: Do you exercise regularly Yes No
If no, why not? ______________
If yes, what kind of exercise____________________________
How often? ____________How long? ______________
Diet: How do you rate your current diet? Good Fair Poor
Changes to health of a family member: _____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
