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______________________________________________________________________
NEW JERSEY RACING COMMISSION WEDNESDAY, MARCH 21, 2012 RENAISSANCE DINING ROOM FREEHOLD RACEWAY FREEHOLD, NEW JERSEY A meeting of the New Jersey Racing Commission was held on Wednesday, March 21,2012, in the Renaissance Dining Room, at Freehold Raceway, located in Freehold, NewJersey. Anthony T. Abbatiello, CommissionerManny E. Aponte, CommissionerPeter J. Cofrancesco, III, Commissio
NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #17 Carol Rees Parrish, R.D., MS, Series Editor When Chyle Leaks: Nutrition Management Options Chylous leakage from the lymphatic system is a complex problem usually resulting from injury or abnormality of the thoracic duct. Although rare, when such leaks occur, they are often difficult to manage and correct. Nutrition therapy plays a major
NAME____________________________________DATE______________________AGE_____