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CEASE Patient Checklist

Generated with MOOJ Proforms

CEASE 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.
Before pregnancy mother and father
Tropical vaccinations: typhoid, yellow fever, cholera, hepatitis A, hepatitis B
Prevention of malaria (Malerone, Lariam)
Diseases with a chronic disturbance: Mononucleosis, Lyme, colitis, asthma
Diseases with a chronic disturbance: epilepsy, depression, migraine, etc
Medication
Sleeping medication
Anti-depressives
Anesthetics
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(Choriongonadotrofin
Injection between 28-30 week w/ AntiRhesus(D)-globulin(rhedQuin,Rhogam Rhophylac
Use of pomades with hydrocortisone
Tobacco smoking or use of drugs: weed, cocaine, ecstasy
Operations
Influenza-vaccination
Additional Comments:
During pregnancy
IVF, Artificial insemination: Clomid, Pregnil
Dental treatment, especially with amalgam fillings
Vaccines, tetanus or tropical vaccinations
Medication in chronic diseases as asthma, colitis, epilepsy or other diseases
Medication against nausea and vomiting, high blood pressure or other
Mantoux (to control if a person has been infected with tuberculosis)
Medication for hypertension
Medication for sexually transmitted diseases
Use of hydrocortisone
Anti-acids: Maalox (aluminiumoxide)
Rennies (with 10 mg aspartame/tablet)
Antibiotics
Nose spray: with xylomethazolin
Vaginal tablets against fungi like Candida: Canesten (dotrimazol), …
Sleeping medication
Inhibitors of contractions of the uterus (prepar, nifedipine)
Injections for maturation of the lungs in case of threatening early delivery
Strong emotional events eventually with medication
use of deodorant(aluminium)
During pregnancy
use of aluminum cooking pots
Antihistaminica
use of soft plastics
Tobacco smoking
Abuse of alcohol
Abuse of coffee
Abuse of drugs like hash, cocaine, weed, etc
Artificial sweeteners: aspartame
chewing gum with aspartame
Diet sodas with aspartame
Paracetamol 500, containing also 40mg aspartame
Additional Comments:
During Delivery
Stimulator of contractions of the uterus (oxytocin)
Medication for pain
Anesthesia
Sedatives
Sleeping medication
Epidural:(containing betamethason, oxytocin, ropivacaine, sufenta[opioid])
Additional Comments:
First 2 years of life
Vaccinations: BCG, Hepatitis B,DTPP/HIB/Pneumococcal, MMR, Meningococcal-C
Vaccinations: varicella, DTPol, tropical vaccinations
Nose spray (Xylomethazoline)
Antibiotics
Anesthetics (e.g. for tubes in the ear drums)
Medication of the mother during breast feeding
Medication against reflux
Examinations with contrast fluids
Inhalors for COPD (asthma)
Pain medication: paracetamol
Antitussives (to suppress cough): promethazin
Warming up of the (plastic) bottle in the microwave
plastic dummies
Plastic vinyl in the sleeping room
soft plastics making contact with food
Anti-diarrhea medication:Loperamide
Antacids with aluminum
Eye drops: Sulphite nitrate
Additional Comments:


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