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    Medical History

    Date of Birth


    Have you ever had a blood transfusion?

    Have you ever been diagnosed with anemia or any other blood related condition?

    All questions contained in this questionnaire are optional and will be kept strictly confidential.



    Are you dieting?

    If yes, are you on a physician prescribed medical diet?



    Number of cups / cans per day?


    Do you drink alcohol?

    If yes, what kind?

    How many drinks per week?

    Are you concerned about the amount you drink?

    Have you considered stopping?

    Have you ever experienced blackouts?

    Are you prone to “binge” drinking?

    Do you drive after drinking?


    Do you use tobacco?

    Cigarettes – pks./day


    Do you currently use recreational or street drugs?

    Have you ever given yourself street drugs with a needle?


    Are you sexually active?

    If yes, are you trying for a pregnancy?

    Women Only

    Age at onset of menstruation

    Date of last menstruation

    Period every ___ days

    Heavy periods, irregularity, spotting, pain, or discharge?

    Number of pregnancies and Number of live births

    Are you pregnant or breastfeeding?

    Have you given birth in the last 12 months?

    Have you had a D&C, hysterectomy, or Cesarean?

    Any urinary tract, bladder, or kidney infections within the last year?

    Any blood in your urine?

    Any problems with control of urination?

    Any hot flashes or sweating at night?

    Do you have menstrual tension, pain, swelling, irritability, etc.?

    Did you recently have breast, lump or nipple discharge?

    Date of last pap and rectal exam?

    Men Only

    Do you usually get up to urinate during the night?

    If yes, # of times

    Do you feel pain or burning with urination?

    Any blood in your urine?

    Do you feel burning discharge from penis?

    Has the force of your urination decreased?

    Do you have any problems emptying your bladder completely?

    Any difficulty with erection or ejaculation?

    Any testicle pain or swelling?

    Date of last prostate exam?