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Print this form,
complete the information and mail to:
Sarah or Stephen Sisselman at 718-780-3827, fax 718-780-7187
Department of Pathology/
Attention Dr Carolyn Salafia
New York Methodist Hospital
506 Sixth Street
Brooklyn, NY 11215
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Please indicate if
there is an additional physician that should receive a copy of your final
report.
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Attach a sheet with
the following information. The more history and details you can supply,
the better.
General Medical
History:
List any major diagnoses, any chronic medications.
If you know your own birthweight, and whether you were delivered at term
or before term, please share that as well.
Reproductive History:
List your pregnancies in order, and tell us how long they last after your
missed period, and how loss was diagnosed (by your bleeding or other symptoms?
by ultrasound without you knowing anything was wrong?), and whether you
miscarried naturally or with a D&C. If your pregnancy delivered a
child, please give us any complications diagnosed during pregnancy (gestational
diabetes? preeclampsia?), your child's birth weight, and at how many weeks
gestation you were delivered.
Family History:
We are particularly interested in high blood pressure, heart attack, stroke,
and diabetes, and especially if such events have happened in you or your
husband's parents, aunts/uncles, siblings. In men we are interested in
diagnoses made before age 55; in women, diagnoses made before age 65.
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