Barron co

MALE MEDICAL HEALTH HISTORY
This medical record is confidential and will not be released to anyone except as may be required by law.
Name:__________________________________________________ Date of Birth _____/_____/________ Age _______
(Last) (First) (MI) mm / dd / yyyy
Reason for visit_____________________________________________________________________________________
Please check if you are allergic to:
□Penicillin
□Zithromax
□Doxycycline
□Sulfa □Amoxicillin □Local anesthetic
□Metal □Rocephin
□Tetracycline
□Latex □Iodine
Other(s): ____________________________________ □No Allergies

List medications, vitamins, over the counter drugs, and/or herbs you take:__________________________________________
Have you recently taken antibiotics □ Yes □ No If yes, when?: for what?: what kind?:
SEXUAL HISTORY:
Have you ever had sex? ____Yes ____ No (if no, go to Social History section)
Are you currently sexually active ____ Yes _____No If Yes, when was the last time you had sex?:_________
Have you or your partner had more than one sex partner in your lifetime? ____ Yes ____ No
Have you or your partner had a new partner in the past 90 days? ____Yes ___No ___Don’t know
Have you or your partner had symptoms or a diagnosis of a sexually transmitted infection in the last 90 days?
____ Yes ____ No ___ Don’t know
Have you or your partner(s) used IV drugs? ___Yes ___ No ____ Don’t know
Check if you have: ___ vaginal sex ___ oral sex ___ anal sex ___sex with men ___sex with women ___sex with both
Check if your partner has: ___vaginal sex ___oral sex ___anal sex ___sex with men ___ sex with women ___ sex with both
Check if you have ever had: ___ Chlamydia ___ Gonorrhea ___ HPV/warts ___ Herpes ___ Syphilis
Do you use condoms? ____Yes, every time ____No ____Sometimes
Does your partner use birth control? ____Yes ____No ____ I don’t know
Are you circumcised? ____Yes ___ No _____I don’t know
REPRODUCTIVE LIFE PLAN:
Do you hope to have any (more) children? ____ Yes ____ No
How many children do you hope to have? ______________
When would you plan your child/children? ________________________________________________________________
What do you plan to do until you (and your partner) are ready to have a baby? ____________________________________
What can I do today to help you achieve your plan? _________________________________________________________

SOCIAL HISTORY:
Do you smoke/chew tobacco? ____ Yes ____ No If, YES, _____# per day Do you want to quit? ____Yes ____ No
Do you drink alcohol? ____Yes ____No Do you use street drugs? ____Yes ____ No
Do you use steroids/performance enhancing drugs? ____Yes ____No
Does alcohol/drugs cause problems in your life and/or are others concerned? ____Yes ____ No
Do you feel threatened or afraid of someone in your life? _____ Yes ____ No
Circle if you do have any other concerns about: Physical abuse /Forced or unwanted sex / Weight / Other:________________
Have you ever received medical care/medications for your mental health? ____Yes ____ No
PAST MEDICAL HISTORY:
Have you ever been in the hospital? ____Yes ____ No If yes, why _____________________________________
Do you have a doctor? ____Yes ____ No If yes, Doctor’s name : ______________________________________
List any medical problems: _______________________________________________________________________
Name of last medical clinic that you visited: _________________________
MALE MEDICAL HEALTH HISTORY Client Name:__________________
Do you now have or have you ever had:
Yes No
___ ___ Sickle cell anemia, trait of Thalassemi ___ ___ Breast Surgery or disease ___ ___ Heart Disease/High blood pressure ___ ___ Thrombophlebitis / blood clot(s) ___ ___ Cancer ___ ___ Diagnosis w/HIV/AIDS ___ ___ Mitral Value Prolapse (MVP) ____ ___ Infection in testicles, scrotum or
___ ___ Blood disorders/Problems ___ ___ Seizure disorder / epilepsy prostate.
with your blood ___ ___ Bariatric surgery ___ ___ Undescended testicle

FAMILY HISTORY:
If you are adopted and do not know your family’s medical history- go to next section.
Does your mother, father, brother, or sister have any of the following: Ovarian Cancer ___Yes ___ No
Stroke ___Yes ___ No
High Blood Pressure ___ Yes ___ No Colorectal/ cancer ___ Yes ___ No REVIEW OF SYSTEMS:
A. General
B. Cardiovascular
C. Genitourinary
□ □ Recent weight gain or loss (+25 lbs) □ □ Chest Pain □ □ Pain or burning with urination □ □ Reactions to drugs or foods □ □ Palpitations □ □ Frequent/ difficult urination □ □ Discharge, itching, irritation, odor D. Musculoskeletal from penis
Yes No
□ □ Bumps rash, sores on penis, groin or scrotum □ □ Have you urinated in past hour? F. Breasts
□ □ Pain or bleeding with sex or ejaculation I. Neuro/Psych
G. Eye, Ears, Nose, Throat
H. Respiratory
□ □ Hearing problems □ □ Chronic cough □ □ Frequent nose bleeds □ □ Shortness of breath/ □ □ Difficulty with memory or speech J. Gastrointestinal
K. Immunizations (check all you’ve had)
□ Tetanus □ Hepatitis A □ Pertussis □ Gardasil/HPV □ □ Nausea/vomiting □ Hepatitis B □ Meningococcal □ Chicken Pox □ □ Changes in bowel habits □ Mumps / Measles / Rubella DIET & EXERCISE: # of servings of the following/per day: ____Dairy ___ Protein ____ Vegetables
How many meals to you eat a day?__________ How much coffee, tea and soda per day?___________ What do you do for physical activity?________________________ How many hours of sleep do you get?_______ To the best of my knowledge the above information is complete and correct.
Patient Signature ____________________________________________________ Date _______/_______/_______
Staff notes: _____________________________________________________________________________________
________________________________________________________________________________________________
Total face-to-face Time:_______________ Counseling Time:________________

Staff Signature: ______________________________________________________ Date _______/_______/_______
Copyright HCET and the WI DPH FP/RSH/EI Program. All rights reserved.

Source: http://www.polkcountyhealthdept.org/app/download/7236987085/10+Male+Medical+Health+History+(English).pdf