FEMALE QUESTIONNAIRE II
Name ____________________________________________
ARE YOU ALLERGIC TO ANY MEDICATIONS? ______________________________________________ ______________________________________________
Have you ever had: (circle all that apply)
______________________________________________ ______________________________________________
Treatment:__________________________________________
______________________________________________
___________________________________________________
___________________________________________________
______________________________________________
Treatment __________________________________________
___________________________________________________
______________________________________________
___________________________________________________
___________________________________________________
______________________________________________
Any other surgeries?_______________________________________________________________
SURGICAL HISTORY
Any reaction to anesthesia? _________________________________________________________
______________________________________________
Any bleeding or blood clotting problems?_______________________________________________
______________________________________________
Any medical conditions run in the family?
What conditions? _______________________________________________________________
______________________________________________
Is there a family history of Ovarian cancer?
______________________________________________ ______________________________________________ ______________________________________________
Did your mother take DES to prevent miscarriage?
FAMILY HISTORY ______________________________________________
Did you have a previous fertility evaluation?
______________________________________________ ______________________________________________
Urine ovulation test kit (LH surge test)?
Pelvic ultrasound to check for ovulation?
______________________________________________
Pelvic ultrasound to check for myomas or fibroids?
______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________
Lupus anticoagulant test (PT, PTT, DRVVT)? No
______________________________________________ FERTILITY EVALUATION ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________
Have you ever had any of these fertility treatments? HOW MANY CYCLES RESULTS
______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________
hCG ovulation trigger injection (Profasi)?
Progesterone (suppos, lozenges, injections)? No
______________________________________________ ______________________________________________ ______________________________________________
Are there any particular concerns you want to address? ___________________________________
FERTILITY TREATMENT ______________________________________________
_______________________________________________________________________________
Sensibilité médicamenteuse Colley, Berger australien, Shetland, Berger blanc suisse et autres bergers Tester la sensibilité d’un chien avant d’appliquer un traitement médicamenteux Sensibilité médicamenteuse liée au gène MDR1 Une mutation dans le gène MDR1 provoque une sensibilité à différents médicaments chez le chien. Lorsque le chien est porteur de cette mutation
Smoking and pregnancy factsheet Smoking and pregnancy factsheet On average, smokers have more complications of pregnancy and labour. This can include bleeding duringpregnancy, placental abruption and premature rupture of membranes. Passive smoking during childhood increases risk for respiratory infections, asthma and impaired lung growth. Passive smoking is a cause of lung cancer in ad