NAME____________________________________DATE______________________AGE_____ LAST MENSTRUAL PERIOD_____________________________________________________ PAST MEDICAL HISTORY (List past significant illnesses and dates) ______________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ SURGERY (List operations and dates) ______________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ CURRENT DRUGS AND MEDICATIONS____________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ALLERGIES___________________________________________________________________ _____________________________________________________________________________ MENSTRUAL AGE OF ONSET______CYCLE_____ (Number of days from start of one period to the start of the next) Length of periods_________________ Menstrual cramps [ ] Mild [ ] Moderate [ ] Severe Menstrual Flow [ ] Light [ ] Normal [ ] Heavy Pre-menstrual symptoms [ ] Yes [ ] No
PREGNANCIES Total Number_______ Number Full Term Births________ Premature births________ Miscarriages________ Abortions________ Number of Living Children____________ SOCIAL HISTORY Smoke Cigarettes [ ] Yes [ ] No How Much? __________ Drink alcohol [ ] Yes [ ] No How Much?_____________ Use drugs [ ] Yes [ ] No Type? ____________ How Often? _________ Birth control [ ] Yes [ ] No Type? _________ If Pills, Name_____________ Last pelvic exam______________ Last Pap smear___________ FAMILY HISTORY
[ ] Diabetes [ ] Tuberculosis [ ] Heart Disease [ ] Breast Cancer [ ] Ovarian Cancer (Both Partners) [ ] Cystic Fibrosis [ ] Hemophilia [ ] Tay-Sacks [ ] Mental Retardation [ ] Other Genetic TREATMENTS
[ ] Semen Analysis [ ] Tubal Dye Test [ ] Hormone Tests [ ] Post CoitalTest [ ] Clomid [ ] Other Fertility Drugs [ ] Insemination [ ] IVF [ ] ICSI [ ] PGD ANY OTHER PROBLEMS YOU WISH TO DISCUSS
[ ] Sexual problems [ ] Verbal/Physical Abuse [ ] Other______________________________________________________________________
INSTITUTO NACIONAL DE ESTADISTICA Y GEOGRAFIA ENCADENAMIENTO de productos del índice nacional de precios al consumidor, correspondiente al mes de junio de 2012. Al margen un logotipo, que dice: Instituto Nacional de Estadística y Geografía. INDICE NACIONAL DE PRECIOS AL CONSUMIDOR Al respecto, hago de su conocimiento que de conformidad con los artículos 59, fracción III, inciso
LIQUID BIOFUELS OF THE FIRST AND SECOND GENERATION – THE METHOD OF PREPARATION AND APPLICATION Ewa Rostek Motor Transport Institute, Centre of Materials Testing and Mechatronics JagielloĔska Street 80, 03-301 Warsaw, POLAND tel. +48 22 438 53 25, fax: +48 22 438 54 01 Krzysztof Biernat Automotive Industry Institute, Department of Fuels and Renewable Energy Jagiell
NAME____________________________________DATE______________________AGE_____