Women’s Health Center PERSONAL AND FAMILY MEDICAL HISTORY Date: __________________________ Allergies: _____________________________________________________________________________________________
______________________________________________________________________________________________________
Medications — Please list all of the medications you are taking, including any vitamins, herbal medicines and “over-the-counter” medications. Name of Medication Frequency Medical History — Please check (;) if you have had any of the following conditions. None
D.V.T. or P.E. (blood clots) G.E.R.D. (reflux)
Bleeding or clotting disorder Liver disease or hepatitis
Other: ____________________________________________________________________________________________
Obstetric and Gynecologic History
Total # of pregnancies: _____________ # of vaginal deliveries: ______________ # of C-sections: ___________________
# of children: _____________________ # of miscarriages: _________________ # of abortions: ____________________
Are you in menopause? Yes No If “no,” please complete the following:
Date of last menstrual period: ______________ # of days between cycles (first day of one to the first day of the next): _____
Date of last Pap Smear: _____________ Have you had any abnormal Pap Smears? Yes No If “yes,” when? _______________
Are you currently sexually active? Yes No Total number of partners in your lifetime: 0 1-5 6-10 >10
My partner(s) is(are): Male Female Both
Have you ever had a sexually transmitted infection or pelvic inflammatory disease? Yes No
If “yes,” which one(s): _________________________________________________________________________________
List any gynecologic procedures or surgeries that you have had: _________________________________________________
____________________________________________________________________________________________________
Method of Birth Control
Other: ____________________________________________________________________
Immunizations — Please provide your most recent immunization dates for .
Tetanus/diphtheria: ________________________________ Hepatitis B: _________________________________________
Tetanus/dipththeria/pertussis _________________________ Varicella: ___________________________________________
Have you ever had chicken pox? Yes No
Please check (;) if you currently have any of the following:Surgical History Please list all the surgeries you have had, including the dates: ___________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Social History Occupation: ___________________________________________________________________________________________
Are you? Married Single Divorced Widowed Separated Significant other Other: ________________
Highest level of education: College High School G.E.D. Other:___________________________________________________________
Do you smoke? Yes No If “yes,” how many cigarettes per day and for how long? _______________________________
Do you drink? Yes No If “yes,” the number of drinks per day:______________________________________________
Have you ever used any recreational drug? Yes No If “yes,” which one(s) and when? ______________________________________
Do you get regular exercise Yes No If “yes,” how often? _________________________________________________
Do you have any dietary restrictions? Yes No If “yes,” what restrictions?_____________________________________
Do you want to discuss abuse? Yes No
Family Medical History Maternal Paternal Condition Father Grandfather/ Grandfather/ Grandmother Grandmother
Course Information and Outline PHRM 409: Advanced Pharmaceutical Analysis [Credit: 4] Fall, 2012 Department of Pharmacy Instructor: Dr. Chowdhury Faiz Hossain, Professor and Dean, FSE. Section 2 Class Hours: 12:40 1:40 (Room-304) Course Objective: To give some ideas on advanced level about the principles and applications of NMR spectroscopy and Mass spect
Jahresbericht wird mit einer grosser Mehrheit angenommen. „nichts haltet mich zurück und was ist so schlimm mit ein paar Mordfällen vor Rechnung 2005 dem Z’vieri“ Blick so leise wie eine Treslag: Startgelderhöhung, Karten etwas günstiger + Wirtschaft ASJM-Schlusslauf kommt ins neue Vereinsjahr Sport-Toto Kartenbeitrag Buechberg erst 2006 Kartenverkauf Zurzacher kommt auch
Women’s Health Center