Times Pharmacy - Contraception Eligibility Questionnaire

Contraception Eligibility Questionnaire

Please answer the following questions to assist us in determining your eligibility to receive contraception. Your privacy is important to us, and all information provided is protected by the HIPAA privacy law. No upfront fees, and we will only charge your insurance after discussing a plan with you in advance.

Name*

Last NameFirst Name

Date of Birth*

Example: 01-01-1999

What is your age?*

Preferred Contact Method*

PhoneEmail

Phone Number*

Area CodePhone Number

Email

Confirmation Emailexample@example.com

Address*

Street, City, State, Zip code

Do you have a Health Insurance Coverage?*

YesNoDon't Know

Insurance Type*

HMSA, Quest, Kaiser, etc.

Are you pregnant or possibly be pregnant?*

YesNo

Have you given birth in the last 6 weeks?*

YesNo

Are you currently breastfeeding a baby less than 6 months of age?*

YesNo

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

YesNo

Are you currently having any abnormal/ unexplained vaginal bleeding?*

YesNo

Do you smoke cigarettes?*

YesNo

Have you ever been told that you have breast cancer?*

YesNo

Have you ever had a stroke, blood clot in your legs or lungs, heart attack, or the risk of having these?*

YesNo

Have you ever been told that you have high blood pressure?*

YesNo

Have you ever been told that you have diabetes (high blood sugar)?*

YesNo

Do you have two or more conditions that could increase your chances of a heart attack, or stroke, such as: smoking, obesity, or diabetes?*

YesNo

Do you have repeated severe headaches, often on one side and/ or pulsating, causing nausea, and which are made worse by light, noise, or movement (migraine)?*

YesNo

Do you have gall bladder disease, serious liver disease, or jaundice (yellow skin or eyes)?*

YesNo

Have you ever been told that you have rheumatic disease such as lupus?*

YesNo

Please list any other medical conditions you may have not mentioned above:*

If not applicable, please type "NONE."

Do you regularly take any medications for tuberculosis (TB) or seizures?*

YesNo

Have you had any bad reactions to contraceptives before?*

YesNoN/A (Not applicable)

Have you ever been told not to take any hormones?*

YesNo

Please list all of the medications and supplements you are taking:*

If not applicable, please type "NONE."

Please list any history and future surgeries:*

If not applicable, please type "NONE."

Please select a pharmacy location you would like to go to