Medical History
Name: | Last STD Test: : ____ _____________ , 20 ___ | |||||
Do you have a Trichomonas or Yeast Infection? | Yes No | |||||
Have you tested Herpes 1 or 2 positive? | Yes No | |||||
Have you tested HIV positive? | Yes No | |||||
Do you have any current symptoms or historical medical problems involving: | ||||||
Heart Liver Lungs Kidneys Bladder, Colon or Rectum Dental | Neck or Spinal Cord Bones or Joints Muscles Mucus Membranes Nasal, Oral, Genital Psychological Other: ___________________________ | |||||
Do you have current symptoms or a medical history of: | ||||||
Hyperventilation Seizures Dizzy Spells Diabetes | High Blood Pressure Fainting Asthma Other: ___________________________ | |||||
Do you wear contact lenses or prescription glasses? | Yes No | |||||
Do you suffer from any fears or phobias? If so, please describe: ________________________________________________________________ ________________________________________________________________ | Yes No | |||||
Do you have any surgical implants? If so, please describe: ________________________________________________________________ | Yes No | |||||
Do you have any piercings of your: | ||||||
Ear(s) Nose Eyebrow(s) Tongue | Nipple(s) Navel Genitals Other: ______________________________ | |||||
Are you currently taking any of the following over-the-counter medications: | ||||||
Aspirin Anti-Inflammatory Antihistamine | Decongestant Expectorant Other: ______________________________ | |||||
List all prescription medications you currently take: | _______________________________________ _______________________________________ _______________________________________ _______________________________________ | |||||
Known Allergies including tapes and contraceptives: | _______________________________________ _______________________________________ _______________________________________ _______________________________________ | |||||
In case of emergency notify: _____________________________________________________________________ | ||||||