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Microsoft word - dr. wisot history.doc

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 Coital Test [ ] Clomid
[ ] Other Fertility Drugs [ ] Insemination [ ] IVF [ ] ICSI [ ] PGD
ANY OTHER PROBLEMS YOU WISH TO DISCUSS
[ ] Sexual problems [ ] Verbal/Physical Abuse
[ ] Other______________________________________________________________________

Source: http://www.reproductivepartners.com/pdf/Dr_Wisot_History.pdf

Inegi

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

Rostek_biernat_silwoj_cimac.pdf

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

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