Birth Control Appointment and Screening Form

Gathers a patient's medical history and preferences ahead of a birth control appointment so the visit can move faster.

Use this template

Name

Nombre

Apellido

Date of birth

Today's Date

Phone Number

Primary care or women's health provider

Provider's contact information

A summary of your visit will be sent to your provider, if you agree

Birth control method(s) you are currently using:

Birth control method(s) you would like at this visit:

Allergies (list name of each medication and your reaction to it)

Birth control history (list each birth control type and your experience with it)

Appointment

Date

Time

Have you had a hysterectomy?

Yes No

Have you had unprotected sex in the last 5 days?

Yes No

Do you think you might be pregnant now?

Yes No

Have you abstained from sex or used a reliable form of birth control since your last period?

Yes No

Have you had a miscarriage or abortion in the last 7 days?

Yes No

Have you given birth within the last 6 months?

Yes No

Are you currently breastfeeding a baby?

Yes No

Do you smoke cigarettes?

Yes No

Do you have or have you ever had breast cancer?

Yes No

Have you ever been told by a medical professional not to take hormones?

Yes No

Do you have vaginal bleeding for an unkown reason?

Yes No

Do you have 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

Have you had bariatric surgery or stomach reduction surgery?

Yes No

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

Do you have diabetes?

Yes No

Do you have high blood pressure or high cholesterol?

Yes No

Have you ever had a heart attack or stroke, or been told you had any heart disease?

Yes No

Have you ever had a blood clot in your leg or in your lung?

Yes No

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

Have you had recent major surgery or are you planning to have surgery in the next 4 weeks?

Yes No

Do you have lupus, rheumatoid arthritis, or any blood disorders?

Yes No

Do you take medications for seizures, tuberculosis, or human immunodeficiency virus (HIV)?

Yes No

If yes, list the medications here.

Do you have any other medical problems or take any other medications, including herbs or supplements?

Yes No

If yes, list them here.

Consent statement

Signature

Sign here

Birth Control Appointment and Screening Form

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