FHCCGLA Form -

Male Medical History

This information is confidential and will be used by your medical provider to make sure you get proper care.

Name: [esiggravity formid=”8″ field_id=”62″ display=”value” ]

Age: [esiggravity formid=”8″ field_id=”63″ display=”value” ]

D.O.B: [esiggravity formid=”8″ field_id=”64″ display=”value” ]

Are you allergic to any medications?: [esiggravity formid=”8″ field_id=”1″ display=”label_value” ]

[esiggravity formid=”8″ field_id=”2″ display=”label_value” ]

Do you take any over the counter medicines, prescription medicines, vitamins, supplements, or home remedies?: [esiggravity formid=”8″ field_id=”3″ display=”label_value” ]

[esiggravity formid=”8″ field_id=”4″ display=”label_value” ]

Do you have a usual source of primary care?: [esiggravity formid=”8″ field_id=”5″ display=”label_value” ]

[esiggravity formid=”8″ field_id=”6″ display=”label_value” ]

A. Family Medical History

Has anyone in your family (mother, father, brother, sister) ever had:

[esiggravity formid=”8″ field_id=”8″ display=”label_value” ]

B. Personal Medical History

Have YOU ever had problems with any of these?

[esiggravity formid=”8″ field_id=”10″ display=”label_value” ]

[esiggravity formid=”8″ field_id=”11″ display=”label_value” ]

1. Have you ever been hospitalized or had any surgery?

[esiggravity formid=”8″ field_id=”12″ display=”label_value” ]

[esiggravity formid=”8″ field_id=”13″ display=”label_value” ]

2. Have you ever had a transfusion or blood exposure?

[esiggravity formid=”8″ field_id=”14″ display=”label_value” ]

3. Have you been immunized against rubella?

[esiggravity formid=”8″ field_id=”15″ display=”label_value” ]

4. Have you been immunized against hepatitis B?

[esiggravity formid=”8″ field_id=”16″ display=”label_value” ]

5. Have you been immunized against HPV with Gardasil?

[esiggravity formid=”8″ field_id=”17″ display=”label_value” ]

6. Have you been immunized against tetanus with Td or Tdap?

[esiggravity formid=”8″ field_id=”18″ display=”label_value” ]

7. When was your last genital exam?

[esiggravity formid=”8″ field_id=”19″ display=”label_value” ]

7a. Were you ever told there was any problem?

[esiggravity formid=”8″ field_id=”20″ display=”label_value” ]

[esiggravity formid=”8″ field_id=”21″ display=”label_value” ]

7B. Have you ever had an HIV test?

[esiggravity formid=”8″ field_id=”22″ display=”label_value” ]

[esiggravity formid=”8″ field_id=”25″ display=”label_value” ]

Was it: [esiggravity formid=”8″ field_id=”24″ display=”label_value” ]

C. Contraception History

1. How old were you when you first had intercourse?

[esiggravity formid=”8″ field_id=”27″ display=”label_value” ]

2. How important is it for you to avoid pregnancy now?

[esiggravity formid=”8″ field_id=”28″ display=”label_value” ]

3. What birth control methods have you and your partner(s) used in the past?

[esiggravity formid=”8″ field_id=”66″ display=”label_value” ]

4. What birth control are you and your partner(s) currently using?

[esiggravity formid=”8″ field_id=”31″ display=”label_value” ]

5. Are you happy with your method?

[esiggravity formid=”8″ field_id=”32″ display=”label_value” ]

6. How often do you use condoms?

[esiggravity formid=”8″ field_id=”33″ display=”label_value” ]

7. Has your partner ever used emergency contraception (morning after pill/Plan B)?

[esiggravity formid=”8″ field_id=”34″ display=”label_value” ]

8. Have you ever gotten anyone pregnant?

[esiggravity formid=”8″ field_id=”36″ display=”label_value” ]

9. Maybe Are you and your partner planning to get pregnant in the next two years?

[esiggravity formid=”8″ field_id=”37″ display=”label_value” ]

D. Habit and Lifestyle

1. How many glasses of an alcoholic beverage do you have per week?

[esiggravity formid=”8″ field_id=”39″ display=”label_value” ]

2. Do you smoke cigarettes?

[esiggravity formid=”8″ field_id=”40″ display=”label_value” ]

[esiggravity formid=”8″ field_id=”41″ display=”label_value” ]

3. Do you use street drugs?

[esiggravity formid=”8″ field_id=”42″ display=”label_value” ]

[esiggravity formid=”8″ field_id=”43″ display=”label_value” ]

4. Have you ever used injected drugs?

[esiggravity formid=”8″ field_id=”44″ display=”label_value” ]

5. Have you ever shared needles?

[esiggravity formid=”8″ field_id=”45″ display=”label_value” ]

6. Has anyone ever told you that you have a problem with drugs or alcohol?

[esiggravity formid=”8″ field_id=”46″ display=”label_value” ]

7. Is anyone, including your partner, threatening you,causing you to be afraid, or hurting you physically?

[esiggravity formid=”8″ field_id=”47″ display=”label_value” ]

8. Have you ever been pressured or forced to have sex when you did not want to?

[esiggravity formid=”8″ field_id=”48″ display=”label_value” ]

9. Have you ever had a sex partner with a history of:

[esiggravity formid=”8″ field_id=”49″ display=”label_value” ]

E. Sexual History

In the last 12 months…

1. Have you been sexually active? If no, skip to #6.

[esiggravity formid=”8″ field_id=”52″ display=”label_value” ]

[esiggravity formid=”8″ field_id=”53″ display=”label_value” ]

2. Have you had sex with:

[esiggravity formid=”8″ field_id=”54″ display=”label_value” ]

3. Have you and/or your partner(s) had:

[esiggravity formid=”8″ field_id=”55″ display=”label_value” ]

4. Have you traded sex for money or drugs?

[esiggravity formid=”8″ field_id=”56″ display=”label_value” ]

5. Do you think that your partner has other sexual partners?

[esiggravity formid=”8″ field_id=”57″ display=”label_value” ]

6. In the last 12 months have you or your sex partner(s) had any of the following:

[esiggravity formid=”8″ field_id=”58″ display=”label_value” ]

[esiggravity formid=”8″ field_id=”59″ display=”label_value” ]

Is there anything else about your health or sexual practices that you would like to discuss with your clinician?

[esiggravity formid=”8″ field_id=”60″ display=”label_value” ]

[esiggravity formid=”8″ field_id=”61″ display=”label_value” ]

Clinician’s Signature: ________________________________

Date: __________________

Clinician’s Signature: ________________________________

Date Updated: __________________

Leave this empty:

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

FHCCGLA https://fhccgla.com

Timestamp

Audit

April 27, 2020 3:34 pm PDT

Male Medical History Uploaded by Admin Name - fdiaz510@gmail.com IP 103.251.19.219