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______________________________________________________________________
ABSTRACTS Part “Oral & Dental Medicine” LABORATORY ABNORMALITIES IN PATIENTS WITH ORAL BURNING A.Krasteva*, A. Kisselova*, Vl. Panov**, V. Dineva*, A. Ivanova***, Z. Krastev*** * Faculty of Dental Medicine, Medical University, Sofia, Bulgaria ** Faculty of Dental Medicine, Medical University, Varna, Bulgaria ***Clinic of Gastroenterology, Hospital “Sveti Ivan Rilski”,
ARTYKU£Y I ROZPRAWY Prawo prywatnemiêdzynarodowe. Zasady wyboruprawa w³aœciwego dla du¿ychryzyk ubezpieczeniowych. Zagadnienia praktyczne 1. Wprowadzenie W dniu 16 maja 2011 r. wesz³a w ¿ycie ustawa z dnia 4 lutego 2011 r. – Pra- wo prywatne miêdzynarodowe 1 (dalej: Ustawa). Ustawa wprowadza zna- cz¹ce regulacje tak¿e dla obrotu ubezpieczeniowego, chocia¿ prima facie mog³
NAME____________________________________DATE______________________AGE_____