Hormonal Contraception Client Assessment
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
1 - When was the first day of your last menstrual period?
*
-
Month
-
Day
Year
Date
2 - Have you ever taken birth control pills, or used a birth control patch, ring, or shot/injection?
*
Yes
No
N/A
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
19a - If yes, list them here:
20 -Do you have any other medical problems or take regular medication?
*
Yes
No
20a - If yes, list them here:
Submit
Should be Empty: