* Required Information
First Name
*
Last Name
*
Date of Birth
*
Allergies
Family History
Questions:
1. What was the first date of your last menstrual period?
2. Have you ever taken birth control pills, or used a birth control patch, ring, or shot/injection?
Yes
No
3. Did you ever experience a bad reaction to using hormonal birth control?
Yes
No
4. Are you currently using birth control pills, or a birth control patch, ring or shot?
Yes
No
5. Have you ever been told by a medical professional not to take hormones?
Yes
No
6. Do you smoke Cigarettes?
Yes
No
7. Do you think you might be pregnant now?
Yes
No
8. Are you given birth within the past 6 weeks?
Yes
No
9. Are you currently breastfeeding an infant who is less than 1 month of age?
Yes
No
10. Do you have diabetes?
Yes
No
11. Do you get migraine headaches, or headaches so bad that you feel sick to your stomach, you lose the ability to see, it makes it hard to be in light, or it involves numbness?
Yes
No
12. Do you have high blood pressure, hypertension, or high cholesterol?
Yes
No
13. Have ever had a heart attack or stroke, or been told you had any heart disease?
Yes
No
14. Have you ever been told by a medical professional that you are at a high risk of developing a blood clot in your leg or in your lung?
Yes
No
15. Have you had a bariatric surgery or stomach reduction surgery?
Yes
No
16. Have you had recent major surgery or are you planning to have surgery in the next 4 weeks?
Yes
No
17. Do you have or have you ever had breast cancer?
Yes
No
18. Do you have or have you ever had hepatitis, liver disease, liver cancer, or gall bladder disease, or do you have jaundice (yellow skin, or eyes)?
Yes
No
19. Do you have lupus, rheumatoid arthritis, or any blood disorders?
Yes
No
20a. Do you take medication for seizures, tuberculosis (TB), fungal infections, or human immunodeficiency virus ( HIV)?
Yes
No
20b. If yes, list them
21. When did you visit your OB/GYN?
22. If you had a birth control before, what is the name of it?
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