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Pacific in vitro fertilization institute

Pacific In Vitro Fertilization Institute
Patient Name: ____________________________

Height: ___________________________
Have you been treated for infertility before: ____No _____Yes Physician(s): ______________________ Date:____________ Physician:______________________ Date:____________ Physician: ______________________ Have you had surgery for varicocele repair? ___No ___Yes Date:____________ Physician: ______________________ Do you have any children conceived with another partner? Do you have or have you ever had: (check all that apply) ____ Blood Transfusion (date____/____/____) ____

What DRUGS have you taken for infertility? (Check all that apply)
Other – Specify ___________________________________ What TESTING have you done for infertility: (Check all that apply) ____ Testicular Physician: ___________________________________ Physician: ___________________________________ Physician: ___________________________________ What TREATMENTS have you had for infertility? (Check all that apply) ____ Artificial Date last cycle__________ Physician:___________________________ Date last cycle__________ Physician:___________________________ SEMEN ANALYSIS Date: ____/____/____ Lab:_____________ mil/ml_____ %mot______ Act______ Date: ____/____/____ Lab:_____________ mil/ml_____ %mot______ Act______ Pacific In Vitro Fertilization Institute
Patient Name: ____________________________
Do you have any medical problems?
Type:______________________________ Date:____/____/____ Treatment: Type:______________________________ Date:____/____/____ Treatment: Are you allergic to any MEDICATION? ____No ____Yes – list all and describe reaction Medication ______________________ Reaction: _______________________________________________ Medication ______________________ Reaction: _______________________________________________ Are you allergic to any FOODS? ____Yes – list all and describe reaction Food ____________________________ Reaction: _______________________________________________ Food ____________________________ Reaction: _______________________________________________ Are you taking any PRESCRIPTION MEDICATIONS? Prescription: _____________________ For: _____________________________________________________ Prescription: _____________________ For: _____________________________________________________ Are you taking any OVER-THE-COUNTER MEDICATION? ____No Medication: _____________________ For: _____________________________________________________ Medication: _____________________ For: _____________________________________________________ Do you take any HERBAL MEDICATINS/VITAMINS or health food supplements? Medication: _____________________ For: _____________________________________________________
Medication: _____________________ For: _____________________________________________________
List any members of your immediate family who have a history of infertility or breast cancer:
Relationship: _______________________ Condition:___________________ Treatment:__________________
How many caffeinated beverages (coffee, tea, soda) do you drink a day? _____________
How many/day:__________ How many years:_____________ started:_____________ Quitting? ______________ #Beer/week_____ #Wine per week_____ #Liquor/week_____ Do you use marijuana, cocaine or other simular drugs? ____No ____Yes - describe________________________________ Do you exercise?
PHYSICIAN NOTES:_________________________________________________________________________________

Source: http://www.pacificinvitro.com/pdf/MaleHistoryForm.pdf

Microsoft word - meerjarenplan 2014 - strategische nota - voor publicatie website.docx

Dit beleidsrapport wordt opgemaakt bij de start van de beleidscyclus (2014) en voor de duur ervan (dus tot 2019). Het geeft inzicht in de wijze waarop het OCMW-bestuur haar strategie wenst te realiseren de komende 6 jaren. Het meerjarenplan start met een strategische nota waarin de prioritaire doelstellingen worden beschreven. Deel 1 In de vorige legislatuur vernieuwde het uitzicht en de werkin


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