Health- Intake form

Name *

First Name Last Name

Date of birth: *

Date

Student ID #: *

Your answers on this form will help your healthcare provider better understand your medical concerns and conditions. The information on this form is confidential and will not be shared with any person or office outside of Hamline University Counseling and Health Services. If you are uncomfortable with any question, please fill in the field with "decline". If it does not apply to you, please fill in the field with "N/A or None" If you cannot remember specific details, please provide your best guess. Thank you!

If you need immediate assistance with a crisis situation, please click this link for a list of 24/7 emergency resources

Personal Medical History: *

Please indicate if you have any chronic or ongoing medical problems. Examples include, but are not limited to clinical depression, anxiety disorder, ADHD, eating disorder, high blood pressure or cholesterol, asthma, diabetes, or cancer. Please specify type if appropriate, such as with cancer.

Surgical/Hospitalization History: *

Please list all prior operations or hospitalizations with dates if you know them.

Medications: *

Prescription & non-prescription medicines, vitamins, home remedies, birth control, herbs, etc. Please note the medication name and your dose (e.g. Medication 10 mg, 2 x per day.)

Allergies: *

(please include allergies to medications, foods, environmental allergies and type of reaction, e.g. rash, hives, anaphylaxis)

Lifestyle/ social history *

Never

Quit (date)

Current Smoker

Packs per day

Number of years

Decline to answer

Do you smoke cigarettes

e-cig/Juul

Pipe

Cigar

Chew/snuff

Hookah

Other (specify)

Decline to answer

Other tobacco

Do you drink alcohol? *

No Yes Decline to answer

Is your alcohol use a concern for you or others? *

No Yes Decline to answer

Do you use recreational drugs? *

No Yes Decline to answer

Have you ever/do you used needles to inject drugs? *

No Yes Decline to answer

Do you use caffeine? (Examples include but are not limited to coffee, tea, soda, energy drinks. *

No Yes Decline to answer

Do you exercise regularly? *

No Yes Decline to answer

Is violence at home a concern for you? *

No Yes Decline to answer

Have you ever been abused? *

No Yes (I would like to talk about it at today's visit) Yes (I don't want to talk about it at today's visit) Unsure Decline to answer

Family History: *

Please indicate immediate family members (mother, father, siblings, maternal/paternal grandparents) with important medical conditions. Examples include, but are not limited to clinical depression or anxiety, high blood pressure, cholesterol, or other heart disease, stroke, asthma, cancer (specify type), diabetes, bleeding/clotting disorders (specify type if able.)

Gynecology:

If applicable, please answer the following questions:

What was the first day of your last menstrual period?

Do you have a menstrual period every month?

No Yes

Date of last PAP test

Have you ever had an abnormal PAP test?

No Yes Unsure

Do you think of yourself as (sexual orientation): *

Straight or heterosexual Lesbian, gay, or homosexual Bisexual Asexual Don’t know Something else Choose not to disclose

What is your partner preference(s), check all that apply: *

Male Female Transgender Male/Trans Man/ Female-to-Male (FTM) Transgender Female/Trans Woman/Male-to-Female (MTF) Genderqueer, neither exclusively male nor female Choose not to disclose

Sexual Contact: *

None Current Past Decline to answer

Date of last sexual contact:

Date

Number of partners in the last 60 days:

Number of partners in the last 12 months:

Sexual practices (check all that apply):

Vaginal Oral Anal insertive Anal receptive Touch with hand Shared sex toys Decline to answer

Condom/Barrier use:

Always

Inconsistent

Never

Not applicable

Decline to answer

Vaginal

Oral

Anal

Do you use any hormonal or other contraception?

No Yes Decline to answer

Have you had the following vaccinations? *

Yes

No

Unsure

Decline to answer

HPV

Hepatitis A

Hepatitis B

Meningococcal

Have you ever been forced or pressured into sex? *

No Yes (I would like to talk about it at today's visit) Yes (I don't want to talk about it at today's visit) Unsure Decline to answer

Signature *

Clear

Health Services

Sexual History: