Number of male sexual partners _____
Number of female sexual partners _____
Method of birth control ___________________
Frequency of sex ____ times per _______
OToo Much OToo Little OJust Right
Do you snore? OYes ONo
Frequency of bowel movements _____times per _____
Do you use any of the following aids:
Contact lenses OYes ONo
Eyeglasses OYes ONo
Sunglasses OYes ONo
Pince nez OYes ONo
Monocle OYes ONo
Night vision goggles OYes ONo
Hearing aid OYes ONo
Ear tubes OYes ONo
Headphones OYes ONo
Braces OYes ONo
Dental plate OYes ONo
Dentures OYes ONo
Mnemonic device OYes ONo
PDA OYes ONo