Professional Pharmacy Birth Control Screening Form
Pharmacy consult and birth control start at $45
Appointment
*
First Name
*
Last Name
*
Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
What was your assigned sex at birth?
Female
Male
Name of your Primary Care Provider (PCP) or Reproductive Health Care Provider (type N/A if you do not have the above providers)
Please answer the following questions about your medical history:
PREGNANCY SCREEN
Do you think you might be pregnant now?
*
Yes
No
Did you have a baby in the past 4 weeks?
*
Yes
No
Did you have a baby less than 6 months ago?
*
Yes
No
Are you fully or nearly-fully breast feeding?
*
Yes
No
Not applicable
Have you had a menstrual period since the delivery of your child?
*
Yes
No
Not applicable
Did your last menstrual period start within the last 7 days?
*
Yes
No
What was the estimated date for the start of your last period?
*
-
Month
-
Day
Year
Date
Type N/A below if you do not know the estimated date for the start of your last period
Have you been using a reliable birth control method consistently and correctly (i.e pills, patch, IUD, implant, coil, injection, vaginal ring, condoms (male and/or female), diaphragm, spermicide, cervical cap)?
*
Yes
No
Have you abstained from sexual intercourse since your last menstrual period or the delivery of your child?
*
Yes
No
MEDICAL HISTORY
Did you have a baby in the past 21 days?
*
Yes
No
Did you have a baby in the past 6 weeks?
*
Yes
No
Have you ever had surgery?
*
Yes
No
List the name of the surgery/procedure below
*
Choose the date of your most recent surgery/procedure below:
-
Month
-
Day
Year
Date
Have you ever had a blood clot in the arms, legs, lungs or other parts of the body?
*
Yes
No
Have you ever been told by your PCP that you are at risk of having a blood clot?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Do you have diabetes?
*
Yes
No
Have you had diabetes for more than 20 years?
*
Yes
No
Are you using insulin?
*
Yes
No
Do you have damage to your eyes, nerves of the feet, hands, kidneys or any other organ from diabetes?
*
Yes
No
Do you have high cholesterol?
*
Yes
No
Have you ever had a heart attack or stroke, or been told you had heart disease?
*
Yes
No
Do you use any form of tobacco, e.g. vape e-cigarette, e-hookah, or e-liquid; chew tobacco, dip snuff, or smoke cigarettes?
*
Yes
No
If you answered YES, how often do you use any form of tobacco?
*
How much tobacco do you use in a day?
*
Do you ever have headaches that start with flashes of light, blind spots, or tingling in your hands or face, that comes and goes away before the headache starts (migraines)?
*
Yes
No
Back
Next
Have you had a recent change in vaginal bleeding that worries you?
*
Yes
No
Have you had stomach reduction or weight loss surgery?
*
Yes
No
Do you have, or have you ever had breast cancer?
*
Yes
No
Have you had a heart, liver, kidney, lung, or other organ transplant?
*
Yes
No
Do you have lupus?
*
Yes
No
Have you ever had hepatitis, liver disease, liver cancer, gall bladder disease, or jaundice (yellow skin/eyes)?
*
Yes
No
Do you have or have you ever had any other medical conditions that we have not discussed?
*
Yes
No
Please list other medical conditions that we have not discussed below:
*
MEDICATION HISTORY
Do you take any medications or supplements?
*
Yes
No
Please list medications and/or supplements you take below:
*
Have you had any allergies or bad reactions to any medication you have taken?
*
Yes
No
Please list any allergies or bad reactions to medications you have taken below:
*
Have you ever been told by a health care provider not to take birth control pills, patch, vaginal ring, injection, implant, diaphragm, intrauterine device (IUD) or coil or any other?
*
Yes
No
Have you ever used birth control in the past?
*
Yes
No
Choose from the menu below of any birth control (pills, patch, vaginal ring, injection, implant, diaphragm, IUD, coil, or any other) you have used in the past
Pill
Patch
Vaginal Ring
Injection
Implant
Diaphragm
IUD
Coil
Other
If you selected OTHER, list below:
When did you last use birth control pills, patch, vaginal ring, injection, implant, diaphragm, IUD or coil, or any other?
-
Month
-
Day
Year
Date
Is there a type of birth control that you would like to use?
*
Yes
No
Please list the type of birth control (birth control pills, patch, vaginal ring, injection) you would like to use below:
*
Pill
Patch
Vaginal ring
Injection
Have you taken emergency contraception in the last 5 days?
*
Yes
No
Submit
Should be Empty: