First Name *

Last Name *

Phone

Date of Birth

Social Security Number

General Information

1. Do You Have any of the following?

a. allergies

Yes

No

If yes, to what

b. Hay fever

Yes

No

c. Asthma

Yes

No

d. Eczema

Yes

No

e. Problems with rashes

Yes

No

If yes, body location

2. Have you ever had a strong allergic reaction (anaphylaxis) or other unexplained reaction during a medical procedure?

Yes

No

If yes, please explain

3. Have you ever had swelling, itching or hives following a vaginal or rectal exam or after contact with a diaphragm or condom?

Yes

No

4. Have you ever had swelling, itching, hives, runny nose or eye irritation, wheezing or asthma during or within one hour after wearing or being examined by someone wearing latex or rubber gloves?

Yes

No

5. Has a physician ever told you that you have a rubber or latex allergy?

Yes

No