Men’s Health History
Name: __________________
1. Reason for your visit.
□ Recheck __________
□ Discharge
□ STD testing/exposure/symptoms
□ Other ____________________________
W______________
9. Caffeine use: □ Never □< 2/day □> 2/day □> 2/week □ >2/month
How long? _________ Type: □ Coffee □ Soda □ Energy drinks
□ Urinary changes
□ Performance issues
2. Breast History: Check all symptoms you are currently experiencing.
□ Breast discharge, color _________, □ Breast changes, ________________
□ Lump in breast □Warm or tender breasts □ Other _________________
□ Do you perform breast self-exams □No □Yes □ Monthly □ Occasionally
3. Genital History: Check all symptoms you are currently experiencing.
□ Circumcised □No □Yes
□ Genital surgery □No □Yes _____________
□ Discharge: color ____________, How long
□ odor
□ Pain: Location ___________ □ Bleeding
□ itching
□ Testicular/Scrotum changes
□ Burning with urination
□ Difficulty initiating urine stream □ Decrease in force of urine stream
□ Decrease in amount of urine flow □ Sore or lesions? ________________
□ Do you perform Testicular self-exams □No □Yes,
How often? □Monthly, □ Occasionally
□ Have you had 3 HPV Vaccines □No □Yes
4. Sexual History:
Have you ever had sex □No □Yes, Age began _________ Last sex_ _______
Number of partners in past 3 months________, lifetime ___________
Sexual preference □ Male □ Female □ Both , Site □ Oral □ Anal □ Vaginal
Birth control method(s) ______________________
Condom usage □ Always □ Usually □ Sometimes □Never
Have you ever had a sexually transmitted disease □No □Yes, ___________
5. Do you have any drug allergies □ No □ Yes List drug and reaction
__________________________________________________________
6. Do you have any food or other allergies □ No □ Yes List and describe the
reaction ______________________________________
7. Current Medications
Name
Dosage
Reason Prescribed
_______________________________________________________
_______________________________________________________
_______________________________________________________
8. Physician prescribed diet □ No □ Yes, type___________________
10. Tobacco Use: □ Never
□ Yes, complete information below.
□ Cigarettes □Never □< 1/2 pk/day □> 1/2 pk/day
□ 1 pk/day □>1 pk/day How Long?_________________
□ Other : Type_________ Amt________ How long? ____________
11. Alcohol Use: □ Never □< 2/day □> 2/day □> 2/week □ >2/month
How long? _________ Type: □ Beer □ Liquor □ Both
12. Illegal drugs: □ Never □< 2/day □> 2/day □> 2/week □ >2/month
How long? _________ Type: ________________
13. Medical History Circle any current medical problems you have. Record
date or year of diagnosis.
Anemia
Mental problems
Asthma
Epilepsy
Migraine Headaches
Bleeding disorder
Heart murmur
Physical limitations
Cancer
Heart problems
Rheumatic Fever
Cerebral Palsy
Hepatitis
Arthritis
Colitis
High blood pressure Scoliosis
Congenital Defect
Irritable bowel
Thyroid problems
Cystic Fibrosis
Kidney stone
Tuberculosis
Diabetes
Medical disability
Pos TB skin test
Other: ______________________________________________
14. List any surgeries with dates: ______________________________
15. List any recent hospitalizations, reason & date:___________________
16. Family History: Complete if this is your first visit. List family member
affected.
Has anyone in your immediate family (parents, siblings, grandparents) had
a history of any of the following?
□ Thyroid problems __________
□ Alzheimer’s/Dementia ________
□ Anemia-Sickle cell _________
□ Asthma/Respiratory _________
□ Bleeding problems _________
□ Cancer ____________________
□ Diabetes _________________
□ Tuberculosis _______________
□ Heart Disease _____________
□ High blood pressure ________
□ Mental/emotional problems ___ □ Stroke ____________________
Is your Mother living
□ Yes □ No
Is your Father living
□ Yes □ No