Emergency Contraception Client Assessment

Emergency Contraception Client Assessment
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Apt or Unit #

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
(1) When was the first day of your last menstrual period?   Date*
(2) Why do you need emergency contraception?*

Recent unprotected sex or birth control failureFuture need
(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, please list here:
Optional Question:
(5) Condoms can help protect from Sexually Transmitted Infections and HIV/AIDS. Do you want condoms for future use? Yes No
Should be Empty: