Moorpark College Student Health Centerhealth History Form

MOORPARK COLLEGE STUDENT HEALTH CENTERHEALTH HISTORY FORM

Last name: ______First Name:______ID#: ______

Allergies:______Current Medications: ______

Sex: Male □ Female □ FTM □ MTF □ Gender non-conforming □

PAST MEDICAL HISTORY

Anemia / □ Yes / □ No / Anxiety / □ Yes / □ No / Asthma / □ Yes / □ No
Blood Clots / □ Yes / □ No / Depression / □ Yes / □ No / Diabetes / □ Yes / □ No
Eating Disorder / □ Yes / □ No / Epilepsy/Seizure / □ Yes / □ No / Headaches / □ Yes / □ No
Head Injury/Concussion / □ Yes / □ No / Hearing Problems / □ Yes / □ No / Heart Disease / □ Yes / □ No
Heart Murmurs / □ Yes / □ No / High Blood Pressure / □ Yes / □ No / High Cholesterol / □ Yes / □ No
Hepatitis / □ Yes / □ No / Kidney Disease / □ Yes / □ No / Liver Disease / □ Yes / □ No
Migraines / □ Yes / □ No / Urinary Tract Infection / □ Yes / □ No / Vision Problems / □ Yes / □ No
Surgeries / □ Yes / □ No / Explain
Hospitalized / □ Yes / □ No / Explain
Major Trauma / □ Yes / □ No / Explain

FAMILY HISTORY (use a check to indicate positive history)

Mother / Father / Grandmother / Grandfather / Sister / Brother
High Blood pressure
Heart Disease
Stroke
High Cholesterol
Liver Disease
Kidney Disease
Diabetes
Depression/Anxiety
Cancer
Neurologic Disease
Other

IMMUNIZATIONS(Circle immunizations that you have had)

Tetanus (Tdap)MMR Hepatitis B Gardasil Chicken Pox Meningitis

SOCIAL HISTORY

Tobacco Use / □ Yes / □ No / Packs/Chews/Vaping per week: / Alcohol Use / □ Yes / □ No / Drinks per week
Drug Use / □ Yes / □ No / Type & Frequency:
Exercise / □ Yes / □ No / Type & Frequency:

SEXUAL HISTORY

Are you sexually active? / □ Yes / □ No / If yes, contraception used:
Number of male partners in the last year / Lifetime / Number of female partners in the last year / Lifetime
Do you engage in? / vaginal sex / □ Yes / □ No / oral sex / □ Yes / □ No / anal sex / □ Yes / □ No
Was any of your partners an IV drug user or bisexual? / □ Yes / □ No
Have you had HIV testing? / □ Yes / □ No
Do you use condoms, dental dams or plastic wraps? / □ Yes / □ No / □ Sometimes

Have you had any of the following infections? (please circle any specific condition that applies to you)

Yeast infection / Bacterial Vaginosis / Trichomonas / Chlamydia
Gonorrhea / Herpes / Warts / HPV
Syphilis / HIV / Molluscum

FEMALES ONLY - OB/GYN HISTORY

Age of first menstruation / Average flow of days / LMP: / Cycle Length
Are your periods regular? / Do you have severe cramps?
Date of last Pap smear: / Do you have a history of abnormal Pap smears? / Date:
Number of Pregnancies: / Live Births: / Miscarriages: / Abortions:

Please circle any specific condition that applies to you

Colposcopy / Cervical Biopsy / Cryotherapy / LEEP
Mammogram / Breast implants / Pelvic Surgery / Ovarian cysts
Fibroids / Endometriosis / Breast Cysts / Nipple Discharge

SIGNATURE: ______DATE: ______rev. July 2017