Barron co

This medical record is confidential and will not be released to anyone except as may be required by law.
Name:__________________________________________________ Date of Birth _____/_____/________ Age _______
(Last) (First) (MI) mm / dd / yyyy
Reason for visit_____________________________________________________________________________________
Please check if you are allergic to:
Sulfa Amoxicillin Local anesthetic
Metal Rocephin
Latex Iodine
Other(s): ____________________________________ No Allergies

List medications, vitamins, over the counter drugs, and/or herbs you take:__________________________________________
Have you recently taken antibiotics □ Yes □ No If yes, when?: for what?: what kind?:
Have you ever had sex? ____Yes ____ No (if no, go to Social History section)
Are you currently sexually active ____ Yes _____No If Yes, when was the last time you had sex?:_________
Have you or your partner had more than one sex partner in your lifetime? ____ Yes ____ No
Have you or your partner had a new partner in the past 90 days? ____Yes ___No ___Don’t know
Have you or your partner had symptoms or a diagnosis of a sexually transmitted infection in the last 90 days?
____ Yes ____ No ___ Don’t know
Have you or your partner(s) used IV drugs? ___Yes ___ No ____ Don’t know
Check if you have: ___ vaginal sex ___ oral sex ___ anal sex ___sex with men ___sex with women ___sex with both
Check if your partner has: ___vaginal sex ___oral sex ___anal sex ___sex with men ___ sex with women ___ sex with both
Check if you have ever had: ___ Chlamydia ___ Gonorrhea ___ HPV/warts ___ Herpes ___ Syphilis
Do you use condoms? ____Yes, every time ____No ____Sometimes
Does your partner use birth control? ____Yes ____No ____ I don’t know
Are you circumcised? ____Yes ___ No _____I don’t know
Do you hope to have any (more) children? ____ Yes ____ No
How many children do you hope to have? ______________
When would you plan your child/children? ________________________________________________________________
What do you plan to do until you (and your partner) are ready to have a baby? ____________________________________
What can I do today to help you achieve your plan? _________________________________________________________


Do you smoke/chew tobacco? ____ Yes ____ No If, YES, _____# per day Do you want to quit? ____Yes ____ No
Do you drink alcohol? ____Yes ____No Do you use street drugs? ____Yes ____ No
Do you use steroids/performance enhancing drugs? ____Yes ____No
Does alcohol/drugs cause problems in your life and/or are others concerned? ____Yes ____ No
Do you feel threatened or afraid of someone in your life? _____ Yes ____ No
Circle if you do have any other concerns about: Physical abuse /Forced or unwanted sex / Weight / Other:________________
Have you ever received medical care/medications for your mental health? ____Yes ____ No
Have you ever been in the hospital? ____Yes ____ No If yes, why _____________________________________
Do you have a doctor? ____Yes ____ No If yes, Doctor’s name : ______________________________________
List any medical problems: _______________________________________________________________________
Name of last medical clinic that you visited: _________________________
MALE MEDICAL HEALTH HISTORY Client Name:__________________
Do you now have or have you ever had:
Yes No
___ ___ Sickle cell anemia, trait of Thalassemi ___ ___ Breast Surgery or disease ___ ___ Heart Disease/High blood pressure ___ ___ Thrombophlebitis / blood clot(s) ___ ___ Cancer ___ ___ Diagnosis w/HIV/AIDS ___ ___ Mitral Value Prolapse (MVP) ____ ___ Infection in testicles, scrotum or
___ ___ Blood disorders/Problems ___ ___ Seizure disorder / epilepsy prostate.
with your blood ___ ___ Bariatric surgery ___ ___ Undescended testicle

If you are adopted and do not know your family’s medical history- go to next section.
Does your mother, father, brother, or sister have any of the following: Ovarian Cancer ___Yes ___ No
Stroke ___Yes ___ No
High Blood Pressure ___ Yes ___ No Colorectal/ cancer ___ Yes ___ No REVIEW OF SYSTEMS:
A. General

B. Cardiovascular
C. Genitourinary
□ □ Recent weight gain or loss (+25 lbs) □ □ Chest Pain □ □ Pain or burning with urination □ □ Reactions to drugs or foods □ □ Palpitations □ □ Frequent/ difficult urination □ □ Discharge, itching, irritation, odor D. Musculoskeletal from penis
Yes No
□ □ Bumps rash, sores on penis, groin or scrotum □ □ Have you urinated in past hour? F. Breasts
□ □ Pain or bleeding with sex or ejaculation I. Neuro/Psych
G. Eye, Ears, Nose, Throat
H. Respiratory
□ □ Hearing problems □ □ Chronic cough □ □ Frequent nose bleeds □ □ Shortness of breath/ □ □ Difficulty with memory or speech J. Gastrointestinal
K. Immunizations (check all you’ve had)
□ Tetanus □ Hepatitis A □ Pertussis □ Gardasil/HPV □ □ Nausea/vomiting □ Hepatitis B □ Meningococcal □ Chicken Pox □ □ Changes in bowel habits □ Mumps / Measles / Rubella DIET & EXERCISE: # of servings of the following/per day: ____Dairy ___ Protein ____ Vegetables
How many meals to you eat a day?__________ How much coffee, tea and soda per day?___________ What do you do for physical activity?________________________ How many hours of sleep do you get?_______ To the best of my knowledge the above information is complete and correct.
Patient Signature ____________________________________________________ Date _______/_______/_______
Staff notes: _____________________________________________________________________________________
Total face-to-face Time:_______________ Counseling Time:________________

Staff Signature: ______________________________________________________ Date _______/_______/_______
Copyright HCET and the WI DPH FP/RSH/EI Program. All rights reserved.


Microsoft word - 2.0 pv 5221 amp.doc

Patient Information CIALIS® (See-AL-iss) (tadalafil) tablets Read the Patient Information about CIALIS before you start taking it and again each time you get a refill. There may be new information. You may also find it helpful to share this information with your partner. This leaflet does not take the place of talking with your doctor. You and your doctor should talk about CIALIS w

Microsoft word - 5121583.doc

Biolife Italiana Srl Technical Sheet N °5121583 BE –1(P) 09/2012 page 1/ 2 TSC AGAR BASE D-CYCLOSERINE ANTIMICROBIC SUPPLEMENT D-CYCLOSERINE 4-MUP SUPPLEMENT Basal medium and selective supplements for the enumeration of C.perfringens in foodstuffs according to ISO 7973 and ISO 15213 TYPICAL FORMULAS TSC Agar Base (g/L) D-Cycloserine Antimicrobic S

Copyright © 2010-2014 Online pdf catalog