tubal reversal medical history
 
tubal reversal medical history

tubal reversal medical history
First Name:
Last Name:
Address 1:
Address 2:
City:
State (if in USA):
Zipcode:
Country:
E-Mail Address:
Re-type E-Mail Address:
Phone:
Your (Female) Age:
Your Height:
Your Weight:
 
Medical History
Have you ever been told in the past, that you have had any of the following? (check all that apply):
Respiratory infections Hepatitis
Psychiatric illness Asthma
Pelvic infections Bleeding tendencies
Tuberculosis Kidney disease
Thrombophlebitis Heart disease
Liver disease Drug addiction
Rheumatic fever Diabetes
Varicose veins High blood pressure
Neurogentic disease Headaches
Anemia Gonorrhea/Syphillis
Sickle Cell Anemia Chlamydia
AIDS Condyloma (Human Papaloma Virus)
Ureaplasma/Mycoplasma Autoimmune Disorder
Endocrine Disease Ovarian Cysts
Multiple Sclerosis Alzheimer's Disease
Abnormal Pap Smear Cancer
Fibroids Pelvic Inflammatory Disease
Thyroid Problems Urinary Problems
Heart Problems Bowel Problems
Ulcers Anesthetic Problems
Hypertension Other
If other, describe:
 
OB/GYNE History
Number of Pregnancies:
Number of Miscarriages:
VIP:
C. Section:
Number of Children:

Ages of Children:

(ctrl for multiple)

Last menstrual period date:
Menstrual Cycle:
Pain Level with period:
Days period lasts:
Age at first menstrual period:

Contraceptives Used:

(ctrl for multiple)

Any Tubular (Ectopic) pregnancy:
Any Therapeutic abortion:
Any Premature Birth:
Any Pregnancy Complication:
History of cancer in family:
List Unusual family illnesses:
 
Other Medical information
Taken any medications:
If yes, describe:
Allergic to any medications:
If yes, describe:
Any hospitalization, surgeries:
If yes, describe:
Any other issues we should know:
Do you authorize exam and treatment:
Guardian:
Date:
 


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