MEDICAL HISTORY Date________________________ Last Name First Name Middle Date of Birth
Address City County State Zip
Age Height Weight Race
Single_________ Married________ Your Phone Number You MUST provide us with your phone number and an emergency number
Emergency Phone Number Emergency Contact Person
Please check how you were referred to our clinic Houston Yellow Pages Houston White Business Pages Spanish Yellow Pages Any Phone Book other than Houston Physician__________________ Friend/Former Patient Name of City____________________ Clinic_____________________ Internet PERSONAL HISTORY Have you ever had or needed treatment for: yes no a. Vaginal infection or Discharge n. Bleeding Tendencies (Hemorrhage) b. Sexually Transmitted Disease (Syphilis, Gonorrhea, o. Lung Disease (Asthma, pneumonia, Trichomoniasis Herpes Chlamydia) tuberculosis) c. Uterine Fibroids p. Anemia or Sickle Cell d. Retroverted (tilted) Uterus q. Liver Disease (Jaundice, hepatitis) e. Kidney or Bladder Infection r. Rheumatic Fever f. Recent flu or high fever s. Epilepsy Seizures g. Severe Abdominal Pain t. Diabetes h. Breast Disease or Cancer u. Blurring of Vision or severe headaches i. Cervical Conization or Cryocauterization v. Unexplained Bruising j. Antibiotics in the past month w. Dizzy or Fainting Spells k. High or Low Blood Pressure or Heart Disease or Murmur x. Severe Depression l. Blood Clots or Phlebitis y. Joint Disease m. Needed a blood transfusion z. Chronic Diarrhea or Constipation If you have answered YES to any of the above, please identify by using the appropriate letter and follow with brief explanation:
Do you or any of your family members have any history of complications with anesthesia? If so, please describe
Please list previous hospitalizations for surgery:
Yes No Do you drink alcohol? if YES how many drinks per day? per week?
Do you smoke? if YES how many packs per day? Do you take Ibuprofen or Aspirin on a regular basis if Yes how often? Have you taken any prescription/non prescription, if YES name the medication or drugs time taken? legal/illegal drugs within 24 hours? At what time did you last eat or drink (including water) _____________a.m. __________________p.m. MEDICAL HISTORY PAGE 2 Name _________________________________________________________Date of birth______________ Last First Middle Please check any medications listed below to which you HAVE HAD an allergic reaction: Penicillin Tetracycline Valium Demerol Lidocaine Adhesive Ampicillin Xylocaine Aspirin Betadine Phenergan Erythromycin Nubain Tylenol Tetanus MENSTRUAL HISTORY ____________LMP(first day of your last normal period) Was this a normal period? ____Yes At approximately what age did your menstrual periods begin____ How many days does your period usually last ?____ Are your periods _____regular (usually at the same time each ____irregular (skip around each month) yes no yes no Do you have tension before a period? Do you experience depression before a period? Do you have cramps with a period? Do you have pain with a period? Do you have hot flashes? Is it possible that you are pregnant at this time? PREGNANCIES DO NOT INCLUDE THIS PREGNANCY Number of Previous Pregnancies Number of Miscarriages Number of Full Term Pregnancies Number of Abortions Number of Premature Births Number of Cesareans Number of Ectopic Pregnancies Did you have excessive bleeding after any of the above? Birthdate of youngest child, if applicable___________ BIRTH CONTROL Are you using a birth control method? If yes, please check: Birth Control Pills Tubal Ligation Birth Control Patch Diaphragm/Cap Depo-Provera Withdrawal Norplant Would you like us to assist you in obtaining a birth control method? [ ] yes [ ] no FAMILY HISTORY Use appropriate letter for family members if any of the following illnesses apply: Mother (M) Father (F) Sister (S) Brother (B) Heart Disease Tuberculosis Diabetes
Mental Disease Arthritis What gynecological service can we provide you with this office visit? __Abortion __Sono __D&C __other
GUIDELINES FOR METABOLIC MONITORING Metabolic Monitoring Tool incorporates recommendations from various guidelines and consensus statements regarding the assessment and ongoing monitoring for metabolic syndrome in patients receiving antipsychotic medications. It is recommended that the Metabolic Monitoring Tool be filled in whenever a client is started on an atypical antipsychotic. A ne
Division of Targeted Research Fax +41(0)31 305 29 70 E-Mail [email protected] NRP Endocrine Disruptors Intermediate Summary Biological activity of complex mixtures of endocrine disruptors Project leader Prof. Dr. Hanspeter Naegeli Project number 4050-66572 English Summary Biological activty of complex estrogenic mixtures There is general concern that the permanent