ongoing Anal or genital 7 ongoing Anal fissures 8 ongoing Hemorrhoids 9 ongoing Urinary tract infection 10 ongoing Excessive anal itching 11 ongoing Excessive flatulence 12 ongoing Part III: Genital Symptoms: Females Only Have you ever experienced any significant medical problems involving the following system/disease? Severity # Body System No Yes Date Outcome Date Med. Taken? Description/Comments Grade Genital/vaginal warts ongoing Pelvic inflammatory disease ongoing Abnormal pap smear
ongoing 7 Anal or genital ongoing 8 Anal fissures ongoing 9 Hemorrhoids ongoing 10 Urinary tract infection ongoing 11 Excessive anal itching ongoing 12 Excessive flatulence ongoing Part III: Genital Symptoms: Females Only Have you ever experienced any significant medical problems involving the following system/disease? # Body System No Yes Date Outcome Date Severity Grade Med. Taken? Description/Comments Genital/vaginal warts ongoing Pelvic inflammatory disease ongoing Abnormal pap smear
MTN-026%20Baseline%20Medical%20History%20Questions%20Form.docx