Form PHS-7057 GYN

PHS-7057 (3/07)

Page 1

PSC Graphics (301) 443-1090

EF

OMB No. xxxx-xxxx; OMB approval expires xx/xx/xx

1. Your age at onset of menstrual cycle:

2. Provide begin/end dates of your last 3 menstrual cycles, regularity, and the type of fl ow:

Begin Date

End Date

Regular or Irregular

Type of Flow

(heavy/moderate/light/spotting)

3. Does cramping exist?

Yes

No

4. Does cramping interfere with normal activities?

Yes

No

N/A

5. Does cramping interfere with athletic and/or recreational activities?

Yes

No

N/A

6. What medication(s) is/are taken for pain relief? If none, please indicate.

7. Have you been examined by a medical provider (GYN, Family Practitioner, Internal Medicine, etc.) for GYN/men-

strual problems?

Yes

No

If yes, when?

(Continued)

PROOF

Department of Health and Human Services

Commissioned Corps of the U.S. Public Health Service

Offi ce of Commissioned Corps Operations

ATTN: Medical Evaluations Offi cer

Suite 100, Plaza Level

1101 Wootton Parkway

Rockville, MD 20852

GYN QUESTIONNAIRE

PRIVACY ACT STATEMENT

AUTHORITY: 42 U.S.C. 202 et seq. and Executive Order 9397.

RECORDS SYSTEM: 09-40-0002, “PHS Commissioned Corps Medical Records,” HHS/PSC/HRS.

PRINCIPAL PURPOSE: To determine medical acceptability or update a medical fi le as part of the application process to the Commissioned

Corps of the U.S. Public Health Service.

ROUTINE USES: None.

DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper an applicant’s

candidacy. Use of the Social Security Number is used for positive identifi cation of records.

NAME

SOCIAL SECURITY NUMBER

INSTRUCTIONS: Please complete the following questions regarding your menstrual cycle. Note: It is intended that this form be completed online as a

link to a ‘Yes’ answer on Item 79 of form PHS-7060, Report of Medical History. In the event an applicant to the Commissioned Corps of the U.S. Public

Health Service cannot complete this form online, the applicant must complete the form in paper format and mail it to the Offi ce of Commissioned Corps

Operations at the above address and mark envelope “To be Opened by Medical Personnel Only.” If more space is needed (for versions of this form without

expandable fi elds), please use the applicable area on page 2.

The public reporting burden for this collection of information is estimated to

average 5 minutes per response, including the time for reviewing instruc-

tions, searching existing data sources, gathering and maintaining the data

needed, and completing and reviewing the collection of information. Send

comments regarding this burden estimate or any other aspect of this col-

lection of information, including suggestions for reducing the burden, to

the HHS / OS Reports Clearance Offi cer, 200 Independence Avenue, SW,

Room 537-H, Washington, DC 20012 (PRA 0990-XXXX). Respondents

should be aware that notwithstanding any other provision of law, no person

shall be subject to any penalty for failing to comply with a collection of infor-

mation if it does not display a currently valid OMB control number.

PHS-7057 (3/07)

Page 2

GYN QUESTIONNAIRE

(Continued)

CERTIFICATION: By signing below, I hereby certify that all the preceding information is true and accurate to the best

of my knowledge.

CONTINUED ANSWERS TO PRECEDING QUESTIONS (If needed when form version does not have expandable fi elds. Please specify question(s)) :

APPLICANT SIGNATURE

DATE

8. What did the medical provider say the problem was?

9. How was the problem treated?

10. Do you currently take birth control medication?

Yes

No

If yes, state the medication, dose and reason for use:

PROOF