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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

C:\documents and settings\lpapina\desktop\march 21 public 2012.wpd

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

nutricritical.com.br

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

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