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 ______________________________________________
_______________________________________________________________________________
Os nervos de Deus não são neurônios Neuroteologia e psicanálise Antes do pai: biologia como figura do materialismo A reportagem de capa da revista Forbes 1 celebra o encontro das neurociências com o marketing produzido uma nova disciplina, o neuromarketing. Existe também a neurofilosofia, que advogando a tese de naturalizar conceitos como desejo, intencionalidade, consciênc
General Information • Fee: $135.00 per camper (including $10.00 for canteen) Please include fees with application. Campers will not be allowed to stay at camp if fee has not been received. A $20.00 late charge will apply for applications received two weeks or less before camp. Fees are non-refundable except with a doctor's note. • Location: Camp Mountainview is • T