Family Planning Pre-screening form

Family Planning Pre-screening form

Family Planning Pre-screening form

Interested in speaking to us about your SRHR needs we recommend that you take this pre-screening questionnaire to help us gather information about you prior to meeting with one of our resident experts. Your answers will be kept confidential, and only used to make sure we provide the right advice for you. This pre-screening and follow up telehealth session is not a replacement for a primary care relationship or annual physical wellness exam. We encourage you to see your health provider at least once a year. By starting a consultation, you consent to our Terms of service and Privacy policy.
Full Name

First NameLast Name
What is your age?
What is your gender?
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
When was your last period?
Have you had any conditions relating to blood clots?
Do you suffer from any of the below listed illnesses?

Other
Check the symptoms that you' re currently experiencing:

Other
Are you currently taking any medication?
Please list them.
Please list them.
Do you smoke?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
Do you have any medication allergies?
How often do you consume alcohol?
Step 3: Let’s help you find your contraceptive. Have you used birth control before?
Are you happy with your birth control?
Which birth control do you prefer?
What kind of contraceptive regimen fits your lifestyle?
Should be Empty: