Year 1 Medical History Questionnaire
Personal Medical History
Section 3: Review of Systems
Please indicate whether you have had a significant problem with any of the symptoms or conditions listed below. If it is a problem that has happened more than once, mark "recurring" as well as all ranges of years in which it happened.
24. GENITOURINARY
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Venereal Disease
syphilis
gonorrhea
herpes
chlamydia
Sexual problems
Decreased sex drive
Vaginal dryness
Yeast infection
Dyspareunia (painful intercourse)
Blood in urine
Burning or pain during urination
Kidney/bladder infection
Difficulty urinating
Awakening at night to urinate
Bladder stones (urinary calculi)
Kidney stones
Breast cancer
Cancer of the cervix
Cancer of the uterus
Cancer of the ovary
Other vaginal conditions
Specify
25. IMMUNE SYSTEM
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
AIDS
Lupus ("SLE")
Leukemia
Chronic Fatigue Syndrome
Raynaud's