*1 - When was the first day of your last menstrual period? Date*
*2 - Have you ever taken birth control pills, or used a birth control patch, ring, or shot/injection? Yes No*
*2a - Have you ever experienced a bad reaction to using hormonal contraception? Yes No N/A*
*2b - Are you currently using birth control pills, or used a birth control patch, ring, or shot/injection? Yes No N/A*
*3 - Have you ever been told by a medical professional not to take hormones? Yes No*
*4 - Do you smoke cigarettes? Yes No*
*5 - Do you think you might be pregnant now? Yes No*
*6 - Have you given birth within the last 6 weeks? Yes No*
*7 - Are you currently breastfeeding an infant who is less than 1 month of age? Yes No*
*8 - Do you have diabetes? Yes No*
*9 - Do you get migraine headaches or headaches so bad that you feel sick to your stomach, lose the ability to see or hard to be in the light, or involves numbness? Yes No*
*10 - Do you have high blood pressure, hypertension, or high cholesterol? Yes No*
*11 - Have you ever had a heart attach, stroke, or been told you have heart disease? Yes No*
*12 - Have you ever had a blood clot in your leg or in your lung? Yes No*
*13 - Have you ever been told by a medical professional that you are at high risk for developing a blood clot in your leg or in your lung? Yes No*
*14 - Have you ever had bariatric or stomach reduction surgery? Yes No*
*15 - Have you had recent major surgery or are you planning to have surgery in the next 4 weeks? Yes No*
*16 - Do you have or have you ever had breast cancer? Yes No*
*17 -Do you have or have you ever had hepatitis, liver disease, liver cancer, gall bladder disease, or do you have jaundice (yellow skin or eyes)? Yes No*
*18 - Do you have lupus, rheumatoid arthritis, or any other blood disorders? Yes No*
*19 - Do you take medication for seizures, tuberculosis (TB), fungal infections, or have human immunodeficiency virus (HIV)? Yes No*
*20 -Do you have any other medical problems or take regular medication? Yes No*