Are there any chronic issues that affect your daily life? These may be treated, untreated, or treatment tried with no results.
List all drug allergies and reaction (if known)
Have you ever had surgery or been hospitalized?Check all that apply.
List all hospitalizations. Include physical and psychiatric admissions.List date, location/department, and reason for admission.
Are you having any of these genitourinary symptoms?
Check all that apply
Are you currently pregnant?
How many times have you been pregnant?If currently pregnant, include this in your count.
How many children have you given live birth to?
Have you given birth via Cesarean "C"-section?
List any pregnancy complications you have had or are experiencing.
Are you on hormone therapy?
Do you know about your genetic family history?If you know your biological family’s medical history, please share it here. If you do not know it, that is okay — you may skip this section.Many adopted patients do not have this information.
How many alcoholic drinks do you regularly consume in a week?
Do you use or are you interested in using PrEP?
PrEP is a prevention medicine protocol for people who do not have HIV.
If you take it correctly, it can greatly reduce your chance of getting HIV.
PrEP is recommended for persons who are sexually active or have high-risk of HIV infection.
Learn More
Do you exercise regularly?Regular exercise is planned, structured, and repeated physical activity performed consistently to meet health guidelines (typically 150 minutes/week moderate aerobic activity or 75 minutes/week vigorous activity, plus muscle-strengthening twice weekly).
Are you interested in a weight management program?