Early Path Medical Consultation Services

Early Path Medical Consultation Services
Pathology Services Working for Safer Pregnancies

Patient Profile
Please submit the following information, using your "tab" key to navigate through the fields. Using your "enter" key will submit your profile. *Please note: An e-mail address and telephone number are required to process your submission. If you would prefer to mail your information to Dr. Salafia, please use our printable form option by clicking here.
Last Name		First Name
Maiden Name		Middle Initial
Date of Birth		Social Security
*Home Phone	( ) -	Home Fax	( ) -
Do we need to call before we fax? Yes No
Street Address		Apt. or Unit #
City		*E-mail
State		Zip
Office Phone	( ) -	Office Fax	( ) -
Do we need to call before we fax? Yes No
Referring Physician
Physician		Specialty
Practice Name		Office Fax	( ) -
Office Address		Office Phone	( ) -
Please indicate below if there are additional Physicians that you would like to have receive a copy of your final report.
Physician 2		Specialty
Practice Name		Office Fax	( ) -
Office Address		Office Phone	( ) -

Medical history: General medical history: 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.