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M:\Data\Personal Health-PH\Administration-AD\AD-1505- Female History Form-09.15.doc KLICKITAT COUNTY HEALTH DEPARTMENT FAMILY PLANNING/STD PROGRAM INFORMATION & HEALTH HISTORY Would you like to become pregnant in the next year ? [ ] Yes [ ] No [ ] Undecided REASON FOR VISIT (check all that apply) __Birth Control__ Pregnancy Test___ Discharge __STD check __Pain:___ UTI HIV test Other (specify) FAMILY HEALTH HISTORY Are you adopted? YES NO Has your biological FATHER, MOTHER, BROTHER(S), OR SISTER(S) ever had: YES NO YES NO High blood pressure Diabetes (z83.3) Heart attack before age 50 ( z82.49) Communicable disease (TB, hepatitis) Stroke (z82.3) Breast, uterine, ovarian, or colon cancer(Z80.3/Z80.49/Z80.41/Z80.0) High cholesterol ( z94.89) Blood clots(z83.2), or kidney disease(Z84.1) Osteoporosis (z82.62) Other Personal Health History YOUR AGE TODAY_____ NAME OF PERSONAL YES NO IF YES, EXPLAIN: Are you allergic to any medications………………………. Are you allergic to Latex(Z91.040) , shellfish(Z91.013), copper, or iodine..... Are you currently taking any medication………………… Have you taken antibiotics in the last 4 weeks………….. Have you had any hospitalizations or surgeries………… YES NO Have you ever had: YES NO Have you ever had: Cancer Gall bladder or liver trouble High blood pressure Routine Childhood Immunizations such as MMR Blood clots in legs or lungs (z86.72) Chlamydia Thyroid problems Gonorrhea Diabetes (high sugar) Venereal warts (HPV) Genital [ ] Cervical [ ] Heart problems/chest pain Genital or oral herpes Epilepsy (seizures, fits) Syphilis Kidney or bladder problems (Z87.440) Pain or problems with sex Mononucleosis (Mono) Frequent or severe headaches Hepatitis/jaundice HIV or exposure to HIV Stroke Exposure to blood products or blood transfusion Anemia (low iron) Other medical or mental problems or illness Please circle- have you had 0 1 2 3 doses of HPV vaccine ? HEALTH RISK BEHAVIORS Do you smoke/use tobacco Y N If yes, how much per day How many years Do you drink alcoholic beverages Y N If yes, how many days per week How many drinks in a day YES NO UNKNOWN Have you or a partner ever used IV drugs in the last 12 months Have you ever had a male bisexual partner Does your partner have any of an infection or HIV Have you or your partner had a positive STD in the last 12 months Have you had 2 or more sexual partners in the past 60 days New partner in the last 60 days In the last 12 months how likely one of your sexual partners has had another sexual partner What kind of sex do you have? Oral Anal Vaginal; With ___Male Female or ____Both ---PAGE BREAK--- M:\Data\Personal Health-PH\Administration-AD\AD-1505- Female History Form-09.15.doc How many sexual partners have you had in the last year? How long have you been having sex with your current sexual partner?______ ARE YOU CURRENTLY HAVING PROBLEMS WITH: YES NO YES NO Bleeding after intercourse A sore on your genitals Bleeding between periods Surgery on female organs Ovarian Domestic violence or being forced to have sex Unusual vaginal discharge, itching, or odor Treated for depression Infection of uterus/tubes Breast lump/biopsy/surgery Have you ever had an Abnormal Pap Date of last pap If you had cryo or biopsy, MENSTRUAL HISTORY: When was the first day of your most recent period was it a normal period Yes No If no, how was it different Do you have regular periods Yes No How old were you when your periods 1st started When not on birth control method, how many days of flow ? Cramps? When on current birth control method, how many days of flow? Cramps? . PREGNANCY HISTORY : How many time have you been pregnant How many live births have you had Have you ever had a miscarriage How many living children do you Do you want to be pregnant now Do you plan to have children in the future_________ Are you currently breastfeeding Date last pregnancy ended What method(s) of birth control are you currently using Any problems with this method Y N If yes, explain Have you had unprotected sex since your last period? (without using a Birth Control method or condoms) __yes __no Are you in need of emergency contraception today or to take home for future emergency use? __yes __no Would you like information on stopping tobacco use __yes __no Current Living situation ; __Homeless__ Married Single, Living alone__ Living with partner Living with parents E-Mail address if you want lab results sent by this method Comments YOUR SIGNATURE DATE: Interpreter signature Date Pt label here File under HISTORY FP/STD FEMALE HISTORY