Reproductive Health History Questionnaire (continued) Men Check any condition that you have or have had: ❑ Testes infection ❑ Testes injury ❑ Testes tumor ❑ Prostatitis ❑ Prostate cancer ❑ X-rays to pelvic area for diagnosis or therapy ❑ Syphilis Date of last prostate examination: _______________ Results?__________________________ Frequency of testicular self-examination: ______________________________ 337 ❑ Pelvic surgery ❑ Herpes ❑ Gonorrhea ❑ Chlamydia ❑ Venereal warts ❑ HIV/AIDS
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