3
Office Use Only
SECTION 2: MALES AND FEMALES: PLEASE COMPLETE THE INFORMATION BELOW.
What kinds of sex have you ever had:
vaginal___ rectal___ oral___
How many sex partners have you had in the past 60 days? NONE ____ ONE ____ MORE THAN ONE _____
Have your lifetime partners included: males___ females ____
Do any of your partners have a history of: (check all that apply)
Injecting Drug Use ___ Multiple partners ___ Sex with females ___ Sex with males ___ Sexually Transmitted Infection or HIV ___
Circle each birth control method below that you or your partner have ever used:
Condoms
Pill
Foam
Sponge
Shots (Depo-Provera)
Film
Implants
Patch
Rhythm
Ring
IUD/ IUS
Withdrawal
Cream
Suppositories
Diaphragm
Cap
Cycle Beads Emergency Contraceptive (Plan B)
Current Method _____________________________
Method Desired __________________________________
List any difficulties you experienced with prior birth control methods, if any: _________________________________________
Office Use Only
SECTION 3: MALES ONLY: How many children do you have?_________
CHECK ANY OF THE CONDITIONS BELOW YOU HAVE EXPERIENCED
___Urinary infection
___Sores, lesions, growths, lumps
___Getting and maintaining an erection
___Blood transfusions
___Swollen lymph nodes
___Hernia
___Breast disease
___Cysts/Tumors
___Is your partner currently pregnant
___Testicular problems
___Anal symptoms
___Complications from anesthesia
CHECK Any OF THE CONDITIONS BELOW YOUR PARTNER HAS EXPERIENCED
___Has your partner had a miscarriage?
___Has your partner had a child?
___Has your partner had a pregnancy termination/ abortion?
Office Use Only
SECTION 4. FEMALES ONLY: PLEASE COMPLETE THE INFORMATION BELOW.
At what age did your period start? _______
How often do you have a period? _______
How long do periods last? ____________
Is flow light or heavy? ________________
Do you ever miss a period? YES ___ NO___
Do you have cramps_______ swelling _______ mood swings _______
When was the date of your last PAP smear? _____________Have you ever had a problem with a PAP smear? YES ____ NO ____
CHECK ANY OF THE CONDITIONS BELOW YOU HAVE EXPERIENCED:
___Pelvic infections
___Sores, lesions, growths, lumps
___Diabetes in pregnancy
___Female problems
___Premature labor
___Twins or history in family
___Breast disease
___High blood pressure in pregnancy
___ Toxemia
___Anal Symptoms
___Urinary infection
___Complications from anesthesia
___Blood transfusions
_____________________________________________________________________________________________________
Other_______________________________________________________________________________________________
NAME, ID # (LABEL)
Form 15-2b (Revised)
4
Section 5.
HISTORY OF PREVIOUS PREGNANCIES:
Date
Weeks
Carried
LEAVE BLANK IF NEVER PREGNANT
Previous Pregnancies
Result: Circle one answer
Type of Delivery
Circle one answer:
Live Birth
Miscarriage
Termination
Stillborn
Vaginal
C-section
Live Birth
Miscarriage
Termination
Stillborn
Vaginal
C-section
Live Birth
Miscarriage
Termination
Stillborn
Vaginal
C-section
Live Birth
Miscarriage
Termination
Stillborn
Vaginal
C-section
Live Birth
Miscarriage
Termination
Stillborn
Vaginal
C-section
Live Birth
Miscarriage
Termination
Stillborn
Vaginal
C-section
Birth Weight
Gender
Place of Delivery
(Male or Female)
Additional Significant Findings:
NAME, ID # (LABEL)
Form 15-2b (Revised)
Complications