Emergency Contraception Client Assessment

Emergency Contraception Client Assessment
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / 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?*

MonthDayYear
Date
(2) Why do you need emergency contraception?*

Recent unprotected sex or birth control failureFuture need
(3) Have you had unprotected sex during the last 5 days?*

YesNoN/A
3a - If yes, when?

MonthDayYear
Date
(4) Are you allergic to any drugs or medications?*

YesNo
4a - If yes, please list here:*
Optional Question:
(5) Condoms can help protect from Sexually Transmitted Infections and HIV/AIDS. Do you want condoms for future use? Yes No
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