PTID: ____ ____ ____ - ____ ____ ____ ____ ____ - ____ ____
MTN-026/IPM 038
Baseline Medical History Questions Form
Complete at the Screening Visit. Record relevant baseline conditions on the Pre-existing Conditions CRF. Relevant conditions include
(but is not limited to): hospitalizations; surgeries; allergies; conditions requiring prescription or chronic medication (lasting for more than
2 weeks); and any conditions currently experienced by the participant. Staff should assess and complete items 1-30 for all screened
participants. Staff are to assess and complete items 31-46 for females participants, as applicable.
Have you ever experienced any significant medical problems involving the following organ/systems?
1
Head, eyes, ears, nose, or throat
2
Prostate
3
Lymphatic
4
Cardiovascular
5
Respiratory
6
Liver
7
Renal (including urinary symptoms)
8
Gastrointestinal
9
Musculoskeletal (including bone fractures)
10
Neurologic
11
Skin
12
Endocrine/Metabolic
13
Hematologic
14
Cancer
15
Drug Allergy
16
Other Allergy
17
Mental Illness
18
Ulcerative colitis or crohns disease
Anal or genital sores or ulcers
20
Dysuria or urethral burning
21
Anal pain
22
Anorectal Bleeding
23
Anal or rectal abscesses
24
Urethral or anal discharge
25
Anal or genital warts
26
Anal fissures
27
Hemorrhoids
28
Urinary tract infection
29
Excessive anal itching
30
Excessive flatulence
MTN-026/IPM 038 BMHQ Form_v1.0_16Nov2015, Page 1 of 2
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Have you ever experienced or are currently experiencing any anogenital symptoms/diagnoses?
19
Yes
Yes
No
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Staff Initials/Date:____________________
PTID: ____ ____ ____ - ____ ____ ____ ____ ____ - ____ ____
MTN-026/IPM 038
Baseline Medical History Questions Form
Complete at the Screening Visit. Record relevant baseline conditions on the Pre-existing Conditions CRF. Relevant conditions include
(but is not limited to): hospitalizations; surgeries; allergies; conditions requiring prescription or chronic medication (lasting for more than
2 weeks); and any conditions currently experienced by the participant. Staff should assess and complete items 1-30 for all screened
participants. Staff are to assess and complete items 31-46 for females participants, as applicable.
Females Only
Have you ever experienced any significant medical problems involving the following organ system/disease?
 N/A
Yes
31
Genital/vaginal warts
32
Pelvic inflammatory disease
33
Abnormal pap smear
No
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In the past 3 months have you experienced any of the following genital symptoms?
 N/A
Yes
34
Genital/vaginal burning
35
Genital/vaginal itching
36
Genital/vaginal pain during sex
37
Post-coital bleeding (bleeding after sex)
38
Genital/vaginal pain not during sex
39
Abnormal genital/vaginal discharge
40
Unusual genital/vaginal odor
41
Dysuria
Have you experienced the absence of a menstrual period (amenorrhea/ic) for the past 6 months?
42
If so, is the absence of menses related to the use of a contraceptive
43
44
Do you currently (e.g. within the last 3 months) experience spotting/bleeding between menses or
frequent bleeding (metrorrhagia)?
Do you currently (e.g. within the last 3 months) experience prolonged and/or heavy menstrual bleeding
(menorrhagia)?
Do you typically experience any premenstrual symptoms? List below.
No
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45
What was the first and last day of your last menstrual period: ___________________
46
For the purposes of scheduling enrollment visit (if otherwise eligible), discuss when the participant anticipates
her next menses to start/end, as applicable. Ideally, menses must not coincide with Study Visits 2-6, therefore
participant’s menstrual cycle must be considered when scheduling the Enrollment Visit (Visit 2).
MTN-026/IPM 038 BMHQ Form_v1.0_16Nov2015, Page 2 of 2
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Staff Initials/Date:____________________