Birth Control Appointment and Screening Form

Name

First NameLast Name

Date of birth

Date

Today's Date

Date

Email

example@example.com

Phone Number

Please enter a valid 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

Have you had a hysterectomy?

YesNo

Have you had unprotected sex in the last 5 days?

YesNo

Do you think you might be pregnant now?

YesNo

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

YesNo

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

YesNo

Have you given birth within the last 6 months?

YesNo

Are you currently breastfeeding a baby?

YesNo

Do you smoke cigarettes?

YesNo

Do you have or have you ever had breast cancer?

YesNo

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

YesNo

Do you have vaginal bleeding for an unkown reason?

YesNo

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?

YesNo

Have you had bariatric surgery or stomach reduction surgery?

YesNo

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)?

YesNo

Do you have diabetes?

YesNo

Do you have high blood pressure or high cholesterol?

YesNo

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

YesNo

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

YesNo

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?

YesNo

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

YesNo

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

YesNo

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

YesNo

If yes, list the medications here.

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

YesNo

If yes, list them here.

I am requesting a birth control consultation and prescription from the pharmacist. I understand the following:

The pharmacist is providing care based on the information I provide.
If the pharmacist is unable to provide my desired method of birth control, I will be given a referral to another healthcare provider.
No method of birth control is 100% effective at preventing pregnancy.
Hormonal birth control does not start working right away to prevent pregnancy. After using hormonal birth control for 7 days, it will prevent pregnancy.
Hormonal birth control does not protect against sexually transmitted diseases (STDs). Condoms protect against STDs.
The pharmacist will review my birth control options. For my selected birth control method, the pharmacist will review how to use it and what to expect. The pharmacist is available to answer all of my questions.
I will contact my pharmacist, primary care provider or women's health provider regarding any side effects, problems, or changes to my health status or medications.
It is advised to have regular visits with a primary care or other reproductive health provider to receive recommended tests and screenings.

Signature

Birth Control Appointment and Screening Form

Demographic Information

Health History