SDSU STUDENT HEALTH CLINIC & COUNSELING SERVICES
Box 2818 Wellness Center, 1440 N. Campus Dr, South Dakota State University Brookings, SD 57007 (605) 688-4157
Please complete form in INK.
Date __________________
General Information
Name ______________________________________________________ Major _____________________ Year: 1 2 3 4 Graduate
Campus Address ______________________________________________________ Birthdate__________________ Age _________
Current prescription medications_____________________________ Non prescription ______________________________________
General Health
Did your mother take DES (hormone) to prevent miscarriage?
❏ Yes ❏ No ❏ Unknown
On a Typical Day:
Servings of Milk/Dairy Products ________
Coffee/Tea/Cola ____________________
In a typical week how often do you:
Exercise___________________________
Servings of Fruit & Vegetables _________
How many cigarettes do you smoke_____
Use Alcohol ________________________
Use Street Drugs____________________
Menstrual History
1. Your age when periods began? ____
2. How many days is it from the first day of your period to the first
day of your next period? ____
3. How many days do you flow? ____
4. Is your flow heavy/moderate/light?
5. # of ____ pads/tampons per day?
6. Cramps: ❏ None ❏ Mild ❏ Moderate ❏ Severe
Sexual History
1.
Have you ever had vaginal sex? ❏ Yes ❏ No
11. Any known STI exposure? _________________________
2.
Have you ever had oral sex? ❏ Yes ❏ No
12. What method of birth control are you now using? _________
3.
Have you ever had anal sex? ❏ Yes ❏ No
________________________________________________
4.
Are you currently sexually active?
5.
Have you had sexual contact with men, women, or both?
❏ Yes ❏ No
❏ Men ❏ Women ❏ Both
How many sexual partners have you had? ____
7.
Has your sexual partner had other sexual partners?
❏ Yes ❏ No ❏ ?
15. What other methods of birth control have you used in the
past?____________________________________________
16. Did you have problems with any methods?
Have you had a change in sexual partners since your last
exam or STI (sexually transmitted infections) screening?
9.
14. Have you had any problems with this method? ___________
________________________________________________
6.
8.
13. How long have you used this method? _________________
❏ Yes ❏ No
________________________________________________
17. Do you have any questions or concerns about the following:
❏ Yes ❏ No
❏ Rape
Have you had sex without using birth control since your last
❏ Sexual communication ❏ Sexually transmitted diseases
period?
❏ Yes ❏ No
10. Do you think you may be pregnant?
❏ Sexual, physical or verbal abuse
❏ Any other area
❏ Yes ❏ No
Personal Health History
Do you now have, or have you ever had:
1. Varicose veins ...................................................❏Yes ❏ No ❏ ?
2. Arm or leg pain, numbness, tingling ..................❏Yes ❏ No ❏ ?
3. Leg pain, redness, swelling ...............................❏Yes ❏ No ❏ ?
4, Painful or frequent urination ..............................❏Yes ❏ No ❏ ?
5. Breast disease, lump, nipple discharge .............❏Yes ❏ No ❏ ?
6. Frequent vaginal infections................................❏Yes ❏ No ❏ ?
7. Unusual vaginal discharge/odor/itching .............❏Yes ❏ No ❏ ?
8. Gonorrhea, herpes, genital warts, Chlamydia ...❏Yes ❏ No ❏ ?
9. Infection of uterus, tubes, ovaries ................... ❏Yes ❏ No ❏ ?
10. Abnormal PAP smear ..................................... ❏Yes ❏ No ❏ ?
11. Pain/bleeding with intercourse ........................ ❏Yes ❏ No ❏ ?
12. History of unusual or irregular periods ............ ❏Yes ❏ No ❏ ?
13. Severe menstrual cramps ............................... ❏Yes ❏ No ❏ ?
14. Premenstrual discomfort ................................. ❏Yes ❏ No ❏ ?
15. Spotting or Bleeding between periods ............ ❏Yes ❏ No ❏ ?
Please explain any “yes” answers: ___________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
2/2011
Complete 1-13 below if you are currently on birth control medication. Are you experiencing or taking:
1. Any problems you think could be caused
by your birth control? ............................................ ❏ Yes ❏ No
2. Nausea or vomiting? .......................................................... ❏ Yes ❏ No
3. Occasional missed periods (no bleeding)? .............. ❏ Yes ❏ No
4. Depression, severe anxiety or mood changes? .... ❏ Yes ❏ No
5. Decreased interest in sex? ............................................. ❏ Yes ❏ No
6. Decreased ability to have orgasms?..................... ❏ Yes ❏ No
7. Weight gain of more than 5 pounds? ................... ❏ Yes ❏ No
8. High blood pressure? ........................................... ❏ Yes ❏ No
9. Any tobacco products? ...................................................... ❏ Yes ❏ No
10. Medicine for seizures?.......................................... ❏ Yes ❏ No
11. Over-the-counter medication or herbs? ................ ❏ Yes ❏ No
12. Difficulty remembering to take your pills? ............. ❏ Yes ❏ No
13. Any of the following danger signals:
Abdominal pain .................................................... ❏ Yes ❏ No
Yellow skin or eyes ............................................................ ❏ Yes ❏ No
Chest pain? ........................................................................... ❏ Yes ❏ No
Headaches which are severe? ............................. ❏ Yes ❏ No
Eye problems, blurred vision, or loss of vision? .... ❏ Yes ❏ No
Severe leg pain? .................................................. ❏ Yes ❏ No
(ACHES is a way for you to remember the danger signals of
hormonal contraceptives.)
Please explain any “yes” answers: __________________________________________________________________________
___________________________________________________________________________________________________________
=================================================FOR CLINIC USE ONLY=============================================
Past Medical and Family History
Health History Form reviewed/updated (initial) ______
Physical Examination
1. Vital Signs Flow Sheet reviewed ______
2. General Appearance .........❏ Normal . . . . . . ❏ Variant
3. Skin .............................................. ❏ Normal . . . . . . ❏ Variant
4. HEENT ..............................❏ Normal . . . . . . ❏ Variant
5. Thyroid ...................................... ❏ Normal . . . . . . ❏ Variant
6. Breast ......................................... ❏ Normal . . . . . . ❏ Variant
7. Heart............................................ ❏ Normal . . . . . . ❏ Variant
8. Lungs .......................................... ❏ Normal . . . . . . ❏ Variant
9. Abdomen ...........................❏ Normal . . . . . . ❏ Variant
10. Extremities.........................❏ Normal . . . . . . ❏ Variant
11. Vulva ........................................... ❏ Normal . . . . . . ❏ Variant
12. Vagina ...............................❏ Normal . . . . . . ❏ Variant
13. Cervix. ......................................... ❏ Normal . . . . . . ❏ Variant
14. Uterus ................................❏ Normal . . . . . . ❏ Variant
15. Adnexa ..............................❏ Normal . . . . . . ❏ Variant
16. Rectovaginal ............................ ❏ Normal . . . . . . ❏ Variant
Laboratory
Hgb ______ PAP ______ Chlamydia ______ GC ______ Wet Mount ______ UA ______ Other ______________________________
Assessment and Plan ____________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Education Counseling
❏ ACHES
❏ Alcohol Cessation
❏ BCP
❏ Calcium
❏ Cholesterol
❏ Dental Health
❏ Diet/Exercise
❏ Multivitamin/Folic Acid
❏ SBE
❏ Skin Exposure to UV Rays
❏ Smoking Cessation
❏ STI/Sexual Health
❏Weight Reduction
❏ Other _____________
__________________
Examiner’s Signature ________________________________________________________________ Date ___________________________
2/2011