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 Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Email Address
example@example.com
When was your last period?
3-4 weeks ago
5-8 weeks ago (If yes. Please visit your doctor)
10 weeks ago or more (If yes. Please visit your doctor)
Have you had any conditions relating to blood clots?
Yes
No
Do you suffer from any of the below listed illnesses?
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Other
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
Are you currently taking any medication?
Yes
No
Please list them.
Please list them.
Do you smoke?
Please Select
Yes
No
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
Do you have any medication allergies?
Yes
No
Not Sure
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Step 3: Let’s help you find your contraceptive. Have you used birth control before?
None
Patch
Pills
Ring
Emergency contraception
Condoms
Other
Are you happy with your birth control?
Yes
No
Which birth control do you prefer?
None
Patch
Pills
NuvaRing
Emergency contraception
Condoms
Other
What kind of contraceptive regimen fits your lifestyle?
Daily intake
Weekly intake
Monthly intake
Emergency solutions
Condoms
Submit
Should be Empty: