EH 1345

Marital status

Living arrangement

Sexual orientation

Total number of sexual partners in the last month

Total number of sexual partners in the last 6 months

Total number of sexual partners in the last 5 years

Current sexual practice

Past sexual practice

Have you had sexual contact with a person who has injected drugs for a non-medical reason? (includes intravenous, intramuscular or subcutaneous injections)

Have you had sexual contact with a person who has hemophilia or another blood clotting disorder who may have received human derived blood clotting factors?

Race

Are you adopted?

Mother

Maternal grandmother

Age at which you had your first period

I sometimes have bleeding after intercourse

I sometimes have bleeding in between my normal periods

Longest number of days of bleeding

Shortest number of days of bleeding

Longest time from the start of one period to the start of the next

Shortest time from the start of one period to the start of the next

Have you ever been told you might have trouble having children?

Have you ever had a pelvic exam?

Have you ever had an abnormal PAP smear?

Tell us about your pregnancy history

First time

Was this a Tattoo or Piercing?

Location on Body:

Sterile Needles Used?

Location on Body:

Sterile Needles Used?

Location on Body:

Sterile Needles Used?

Was this a Tattoo or Piercing?

Location on Body:

Sterile Needles Used?

Athletic talents

Athletic talents (Other)

Interests or Hobbies

Interests or Hobbies (Other)

Amount of exercise

Type of exercise

Type of diet

Quality of diet

Type of exercise (other)

Have you injected drugs for a non-medical reason in the last 5 years?

Do you have hemophilia and/or received human-derived clotting factor concentrates in the last 5 years?

Have you in the last 12 months lived in the same dwelling with another person with hepatitis B infection or hepatitis C infection?

Have you been exposed in the preceding 12 months to known or suspected HIV (AIDS), Hepatitis B, and/or Hepatitis C infected blood through a needle stick or through contact with an open wound, non-intact skin, or mucous membrane?

Have you ever been diagnosed with any form of hepatitis?

Have you been in juvenile detention, lock up, jail or prison in the last 12 months?

In the last 12 months, have you gotten a new tattoo, ear piercing or body piercing, or had acupuncture treatment in which NON STERILE instruments may have been used?

In the last 8 weeks, did you receive a smallpox vaccination (vaccinia virus)?

In the last 12 months, have you had any contact with someone who received a smallpox vaccination or who was diagnosed with smallpox?

Have you ever been diagnosed with smallpox?

Birth defects / Congenital abnormalities

Chromosome abnormalities

Specific genetic mutations and variants

Cancer

Has one or more blood relatives been diagnosed with CJD?

Have you ever received injections of human pituitary-derived growth hormone?

Have you ever received a dura mater transplant?

Have you ever been diagnosed with dementia or any degenerative or demyelinating disease of the central nervous system (CNS) or other neurological disease of unknown etiology?

Family Birth defects / Congenital abnormalities

Family Chromosome abnormalities

Family - Specific genetic mutations and variants

Family - Cancer

Family Cancer (Other)

High school

College

What is/was your college major?

What college degrees have you earned?

Trade school