Reproductive Health History Questionnaire Name: ________________________________________ Date: _________________________ Gender: (circle one) Male Female Date of birth: ____________________________ Date of employment: _____________________ Job title: ___________________________________ Description of job: Diet and Physical Activity Weight: _____________ Height: ____________________ Have you lost more than 20 pounds in the last year? (yes or no)__________________________ Do you follow a particular food diet or have any special dietary habits? (yes or no)____________ If yes, specify: _______________________________________________________________ List the types and frequency of regular vigorous exercise: _____________________________________________________ _______________________________________________________________________________________________________ List physical requirements of job: ❑ Bending ____________________________ ❑ Sitting ____________________________ ____________________________ ____________________________ ❑ Climbing ____________________________ ❑ Standing ____________________________ ____________________________ ____________________________ ❑ Lifting ____________________________ ❑ Stooping ____________________________ ____________________________ ____________________________ ❑ Pulling ____________________________ ❑ Twisting ____________________________ ____________________________ ____________________________ 333