Birth Control Consultation

General Patient Information
Appointment*
Patient Name*

First Last
Patient Gender*
Patient Birth Date*

MonthDayYear
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Patient Height *
Patient Weight (lbs)*
Patient E-Mail*
Patient Medical History
Please list any drug allergies
Are you pregnant?*

YesNo
Did your last menstrual period start within the past 7 days*

YesNo
Have you given birth in the last 6 months or are you breastfeeding currently?*

YesNo
Have you received an organ transplant?*

YesNo
Choose if you have history of any of the following*

Breast CancerLupusDiabetes (>20 years)Active CancerHigh CholesterolHigh Blood PressureHeart FailureAtrial FibrillationLiver diseaseGall Bladder DiseaseBlood ClotsNone of the above
Please list your Current Medications*
Healthy & Unhealthy Habits
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?*

No0-1 pack/day1-2 packs/day2+ packs/dayVape productsE-cigarettes
Include other comments regarding your Medical History
Should be Empty:

General Patient Information