Check any of the following infectious diseases you have had. Where appropriate, list your age at the time of the infection and any special circumstances surrounding the time of the infection (e.g., your entire first grade class got the chicken pox; you got mononucleosis at a time of high stress) in the box provided.
| Athlete's foot | Lyme disease | Scarlet fever |
| Chicken pox | Malaria | Shingles |
| Chlamydia | Measles | Strep throat |
| Cold sores (HSV) | Meningitis | Syphilis |
| Diphtheria | Mononucleosis | Tetanus |
| Encephalitis | Mumps | Toxic shock syndrome |
| Genital herpes (HSV) | Whooping cough (pertussis) | Trichomoniasis |
| Genital warts (HPV) | Pinworm | Tuberculosis |
| Giardiasis | Pneumonia | Ulcer (H. pylori) |
| Gonorrhea | Poliomyelitis | Urinary tract infection |
| Hepatitis A | Pubic lice | Warts (site: __________) |
| Hepatitis B | Rabies | Yeast infection |
| Hepatitis C | Rheumatic fever | Other: |
| HIV infection | Ringworm | Other: |
| Influenza | Rubella (German measles) | Other: |
| Jock itch | Scabies | Other: |
| Disease | Age | Circumstances |
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