Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Gender
Male
Female
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone
(###)
###
####
Race
White
Black or African American
Asian
Native American or Alaska Native
Native Hawaiian or Pacific Islander
Decline to Provide
Other
Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
Decline to Provide
Marital Status
Single
Married
Divorced
Widowed
Education
Occupation
Reason for Participation
What is your reason for participation in this program?
Other?
Please check all that apply to you
Please check all that apply to you
Have you recently experienced any of the following?
Please check all that apply to you
Date of Last Pap Smear and/or Pelvic Exam
Check those that apply to you
List any prescription medications you are now taking:
List any self-prescribed medications, dietary supplements, or vitamins you are now taking:
List any drug allergies
Date of last physical exam:
MM
DD
YYYY
Was this exam
Normal
Abnormal
Never had one
Can't remember
Have you ever smoked cigarettes, cigars, or a pipe?
Yes, Cigarettes Past
Yes, Cigarettes Currently
Yes, Cigars Past
Yes, Cigars Currently
Yes, Pipe Past
Yes, Pipe Currently
None of the above
Do you drink alcoholic beverages?
Yes
No
If yes,
My current height is:
My current weight is:
