CEASE Patient Checklist Please List all important health aspects including medications, vaccinations and other pertinent information. Please use this form as a guideline to provide necessary information. Patient Name(*) Invalid Input Email Address(*) Invalid Input Phone Number Invalid Input Before pregnancy mother and father Tropical vaccinations typhoid, yellow fever, cholera, hepatitis A, hepatitis BPrevention of malaria (Malerone, Lariam)Diseases with a chronic disturbance: Mononucleosis, Lyme, colitis, asthmaDiseases with a chronic disturbance: epilepsy, depression, migraine, etcMedicationSleeping medicationAnti-depressivesAnesthetics Dental fillings with amalgam (mercury)Tetanus vaccine in case of wounds (tetanus toxoid)Hepatitis B vaccine for physicians, nurses, lab analysts, etc.IVF(invitrofertilization):Clomid(Clomifeen),Pregnil(ChoriongonadotrofinInjection between 28-30 week w/ AntiRhesus(D)-globulin(rhedQuin,Rhogam RhophylacUse of pomades with hydrocortisoneTobacco smoking or use of drugs: weed, cocaine, ecstasyOperationsInfluenza-vaccinationInvalid Input Additional Comments Invalid Input During pregnancy IVF, Artificial insemination: Clomid, PregnilDental treatment, especially with amalgam fillingsVaccines, tetanus or tropical vaccinationsMedication in chronic diseases as asthma, colitis, epilepsy or other diseasesMedication against nausea and vomiting, high blood pressure or otherMantoux (to control if a person has been infected with tuberculosis)Medication for hypertensionMedication for sexually transmitted diseasesUse of hydrocortisoneAnti-acids: Maalox (aluminiumoxide)Rennies (with 10 mg aspartame/tablet)AntibioticsNose spray: with xylomethazolinVaginal tablets against fungi like Candida: Canesten (dotrimazol), …Sleeping medicationInhibitors of contractions of the uterus (prepar, nifedipine)Injections for maturation of the lungs in case of threatening early deliveryStrong emotional events eventually with medicationuse of deodorant(aluminium)use of aluminum cooking potsAntihistaminicause of soft plasticsTobacco smokingAbuse of alcoholAbuse of coffeeAbuse of drugs like hash, cocaine, weed, etcArtificial sweeteners: aspartamechewing gum with aspartameDiet sodas with aspartameParacetamol 500, containing also 40mg aspartameInvalid Input Additional Comments Invalid Input Verification(*) Invalid Input
