Please answer the following questionsFirst Name* Last Name* Phone Date of Birth MM slash DD slash YYYY Social Security Number General Information1. Do You Have any of the following?a. allergies Yes No If yes, to whatb. Hay fever Yes No c. Asthma Yes No d. Eczema Yes No e. Problems with rashes Yes No If yes, body location2. Have you ever had a strong allergic reaction (anaphylaxis) or other unexplained reaction during a medical procedure? Yes No If so, please explain3. 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
