1. Step
A B AB 0           RH - RH +
Fair Medium Dark Ebony

Black Brown Green
Blue Hazel Other

Miyop
Hipermetrop
Astigmat
Black Brown Blonde Red Other
Straight Wavy Curly       Thin Thick

Right Hand Left Hand

Literate Grammar School Middle School High School University PhD & Above

Single, no sexual partner Single, has sexual partner Engaged Married Comitted to life partner Separated or divorced

Muslim Christian Jewish Budist Other

Now At a future date :


2. Step
Homemaker I work full time I work part time Currently unemployed

Turkish English German Other...Please type :

I currently smoke

I quit smoking
I never smoked



I always drink alcohol


I rarely drink alcohol
I never drink alcohol



I currently use illegal drugs


I used to use illegal drugs but I quit
I am currently using over legal drugs


I use drugs for therapeutic purposes, please clarify :


3. Step

I have and still do work as a prostitute

I have had.... Sexual partners :
I have contracted sexually transmitted diseases. Please clarify
I am currently in a monogomous relationship

I have never engaged in sexual interourse



I have never had any legal trouble

I have had legal trouble. If yes, then please explain the kind of legal trouble you have had :



No Yes, please explain :


No Yes, please explain :

Depression
Schizophrenia
Manic depression
Obsessive complusive disorder
Mania
Other, please explain : :
Anorexia or bulimia


No Yes, please explain :


No Yes, please explain :

4. Step




Yes No

Light Moderate Heavy Very Heavy

How many times have you been pregnant (0-?) : How many times have you given birth (0-?) : Were there any complications during the pregnancy or delivery? If yes, please explain :

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes



5. Step





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