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Microsoft word - new medical history.wpsMEDICAL HISTORY
Last Name First Name Middle Date of Birth
Address City County State Zip
Age Height Weight Race
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
Name of City____________________
Have you ever had or needed treatment for:
a. Vaginal infection or Discharge
n. Bleeding Tendencies (Hemorrhage)
b. Sexually Transmitted Disease (Syphilis, Gonorrhea,
o. Lung Disease (Asthma, pneumonia,
Trichomoniasis Herpes Chlamydia)
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
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:
Do you drink alcohol?
if YES how many drinks per day?
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
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:
Tetracycline Valium Demerol Lidocaine
Nubain Tylenol Tetanus
____________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?
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___________
Are you using a birth control method? If yes, please check:
Birth Control Pills
Birth Control Patch
Would you like us to assist you in obtaining a birth control method? [ ] yes [ ] no
Use appropriate letter for family members if any of the following illnesses apply:
Mother (M) Father (F) Sister (S) Brother (B)
What gynecological service can we provide you with this office visit?
__Sono __D&C __other
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