Contraceptive Use Assessment
Please complete this assessment to help us understand your contraceptive use and related needs. Your responses are confidential and will be used to improve support and services.
Age Group
*
Please Select
Under 18
18-24
25-34
35-44
45 and above
What is your current marital status?
*
Single
Married/Partnered
Divorced/Separated
Widowed
Other
Are you currently using any contraceptive method?
*
Yes
No
If yes, which contraceptive method(s) are you currently using? (Select all that apply)
Oral contraceptive pills
Condoms
Intrauterine device (IUD)
Implant
Injection
Natural methods (e.g., withdrawal, calendar)
Other
If not using contraception, what is the main reason?
Currently trying to conceive
Not sexually active
Concern about side effects
Lack of access or cost
Partner does not approve
Other
How long have you been using your current contraceptive method?
Please Select
Less than 6 months
6-12 months
1-3 years
More than 3 years
Would you like to receive counseling or more information about contraceptive options?
*
Yes
No
Submit Assessment
Should be Empty: