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Allergies to medications/food/environment

Desert West Obstetrics and Gynecology, Ltd. Name ________________________________ Birthdate_________ Age _____ Date____________ Allergies to medications/food/environment
Current Medications
Reason Used
(Prescription, over the counter, herbal) Prescribing Doctor
What do you do so you don't become pregnant? ____ Diaphragm ____ Other ___________________________________________________________________ First day of last period_________________________________ What age were you when you started your first period? ______________ Are your periods regular? ____________________ Is there bleeding between periods? ____________ How often do your cycles occur? ___________________________ For how many days do you bleed? __________________________ Flow is: ______ scant ______ mild ______ mod ______ severe ______ incapacitating Other symptoms with periods? ______________________________________________________________ _______________________________________________________________________________________ Date of last pap smear ___________________________________ How? ________________________________________________________________________ When was your last Mammogram (if any)? ___________________ Result ___________________________ Do you have concerns about your breasts? ____________________________________________________ When was your last Bone Density (if any)? ___________________ Result ___________________________ Past Medical / Surgical History(Include injuries and conditions requiring
medication -i.e. -high blood pressure, seizures, diabetes, etc)

Desert West Obstetrics and Gynecology, Ltd. Name ________________________________ Birthdate_________ Age _____ Date____________ Have you had: Total number of pregnancies
Pregnancy Details
Number of
Delivery Obstetrical/Neonatal
Delivery Doctor
Family History
Please complete if any of your close relatives have had any of the following: Family Members 1st
Cause of Death
Family Member
Desert West Obstetrics and Gynecology, Ltd. Name ________________________________ Birthdate_________ Age _____ Date____________
Social History
Primary Language Spoken____________________________________
Do you smoke? No_____ Yes_____ If yes, type of tobacco?_______________ Number of years_____ Pks/day_____ Do you drink alcohol? No_____ Yes_____ If yes, type of alcohol____________________________________________ How often?__________________________ Amount______________________ Last drink________________________ Do you consume caffeine? No_____ Yes_____ If yes, what kind?_______________ Amount_____________________ Do you use recreational drugs? No_____ Yes_____ If yes, what kind?_______________________________________ Exercise frequency? Daily_____ Never_____ Occasional_____ 2-3times/wk_____ 4 or more times/wk_____ How many sexual partners do you have? None_____ One_____ 2-5_____ 5+_____ Have you been exposed to sexual or physical violence or abuse? Are there animals in the home? No_____ Yes_____ If yes, what kind?_______________________________________ Is the patient the individual who cleans up after the animals? If medically necessary, would you agree to a transfusion? REVIEW OF SYSTEMS
If you are experiencing any of the symptoms listed, PLEASE CIRCLE THE ONES THAT APPLY, or write NONE.
Constitutional (Health in General): Fatigue, fever, night sweats
Ears, Nose, Mouth and Throat:
Eye discharge, vision loss, ear drainage, hearing loss, nasal drainage

Cough, wheezing, difficulty breathing or shortness of breath
Chest pain, irregular heartbeat, palpitations
Gastrointestinal: Abdominal pain, constipation, diarrhea, vomiting
Genitourinary: Painful periods, pain with urination, blood in urine, excessive menstrual bleeding, vaginal discharge
Neurologic/Psychiatric: Walking or balance difficulties, depression, anxiety, mood swings
Dermatologic: Skin itching, rash
Musculoskeletal: Bone weakness, joint weakness
Hematology: Easy bleeding, easy bruising
Immunology: Environmental allergies, food allergies


C. G. Bhakta Institute of Biotechnology(CGBIBT) Maliba Campus, Bardoli, Surat(District),Gujarat,India-394 350 Designation :-Director,CGBIBT,Uka Tarsadia University Dean,Faculty of Science,Uka Tarsadia University Residence :- +91261-2666972;Office : +912625-254122 U.G.:- B.Sc., University of Madras(1981) P.G.:- M.Sc., University of Madras(1983) Ph. D.:- Ph.D., M.S. University of Barod

ORIGINALARTICLE The Carbohydrate and Caloric Content of Concomitant Medications for Children with Epilepsy on the Ketogenic Diet Denis Lebel, Caroline Morin, Micheline Laberge, Nathalie Achim and Lionel Carmant ABSTRACT: Background: The ketogenic diet for children with refractory epilepsy requires a strict control of the amount of ingested carbohydrates. This can be altered by medicati

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