Annual Health History FormToday’s Date______

Reproductive Health Program

Please ask the front desk staff if you would like help filling out this form

Name ______

First Middle Last

Date of Birth: ______Name You Want to be Called: ______

Current Gender Identity:

Female Male Transgender Male/Trans Man/Female to Male (FTM)

Transgender Female/Trans Woman/Male to Female (MTF)

Genderqueer, neither purely male or female Other (please name) ______

Decline to Answer

Preferred Gender Pronoun: She/Her He/Him Other (please name): ______

  1. Why are you here today?

______

  1. Are you taking any medicines?

Yes (Please list any prescription, over the counter, vitamins, herbs.) No, I do not take any medicines.

Name of medicine / Strength/Dose / Why do you take this medicine?
Example: Zrytec / 20 mg / Allergies
  1. Have you had any new allergic reactions (bad reaction) to a medicine, a shot, or anything else since your first visit here?

No allergies ever No new allergies (same as before) Yes (Please explain below)

What caused the reaction? ______Reaction: ______

  1. Family Health History: Have your Mother, Father, Sister(s) and/or Brother(s) had any new health problems since your last visit?

Yes, what? ______No

  1. Your health history: since your last visit have you had any of the following? (Check all that apply)

Anemia (low blood iron)
Heart Trouble
Tuberculosis (TB)
Pelvic Inflammatory Disease
Headaches
Epilepsy (fits, seizures)
Anxiety (nerves, panic attacks) / Asthma (wheezing)
Cancer
Liver Trouble
Hepatitis
High Blood Pressure
Depression (feeling down or blue)
Problems with Uterus or Testicles / Diabetes (sugar)
Gallbladder Trouble
Blood Clot
Ulcers
Lupus
Blood Clotting Trouble
Exposed to Diethylstilbestrol
STD, VD (syphilis, gonorrhea, chlamydia, herpes, warts, HIV, hepatitis B)
Other ______
  1. Have you been a patient in a hospital overnight or had surgery (an operation) since your last visit here?

Yes (If yes, explain EACH reason and when) No. (If no, go to question #7)

I was in the hospital/had surgery because / When
Example: broke my arm / 6 months ago
  1. Have you had any HPV vaccines (shots) since your last visit here? Yes No
  2. What do you use for birth control? ______

What birth control methods have you used before? ______

What problems have you had with these birth control methods? ______

  1. How many sex partners have you had in the past year? _____ In the last 3 months? ______
  2. Have you had unprotected sex with someone since your last visit here who (check all that apply):

Used IV drugs, Had other sex partners while still having sex with you

Had HIV or an STD Had men and women sex partners

  1. Safe Relationships:
  • Has your current partner ever threatened you or made you feel afraid? Yes No

(Threatened to hurt you or your children if you did or did not do something,

controlled who you talked to or where you went, or gone into rages)

  • Has your partner ever hit, choked or physically hurt you? Yes No
  • Has your partner ever forced you to do something sexually Yes No

that you did not want to do, or refused your request to use condoms?

  • Does your partner support your decision about when or if you want Yes No

to become pregnant?

  • Has your partner ever tampered with your birth control Yes No

or tried to get you pregnant when you didn’t want to be?

  1. Do you have children now? Yes No

Do you want (more) children? Yes No

How many (more) children do you want and when? ______

  1. In the past two weeks, how often have you been bothered by having little interest or pleasure in doing things?

Not at all Several days More than half the days Nearly every day Don’t know

  1. In the past two weeks, how often have you been bothered by feeling down, depressed, or hopeless?

Not at all Several days More than half the days Nearly every day

FOR WOMEN ONLY
  1. Have you been pregnant since your last visit here? (if no, go to question #17) Yes No

How many times?______How many children have you given birth to? ______

How many miscarriages? _____ How many abortions? ____ Date last pregnancy ended: ______

  1. Are you breastfeeding now? Yes No
  2. Do you have a period each month? (if no, go to question #18) Yes No

When was the first day of your last period? ______

Do you have cramps with your period? Yes No

  1. Since your last visit here:

Have you had a PAP smear? (if no, go to question #19) Yes No

Date of last PAP

Have you had a PAP smear that was not normal? Yes No

Have you tested positive for HPV? Yes No

Have you had a colposcopy (looking at your cervix with a microscope)? Yes, date ______No

Have you had a mammogram (breast x-ray)? Yes, date ______No

Have you been tested Chlamydia since your last visit? Yes, date ______No

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