(1) When was the first day of your last menstrual period? Date*
(3) Have you had unprotected sex during the last 5 days? Yes No N/A* If yes, when? Date
(4) Are you allergic to any drugs or medications? Yes No* field. If Yes, which ones?
Optional Question:(5) Condoms can help protect from Sexually Transmitted Infections and HIV/AIDS. Do you want condoms for future use? Yes No