Emergency Contraception Side Effects Report Form
Please use this form to report any side effects experienced after using emergency contraception. Your responses help us improve safety monitoring and follow-up.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Which emergency contraception did you use?
*
Please Select
Levonorgestrel (Plan B One-Step or generic)
Ulipristal acetate (ella)
Copper IUD
Not sure
Other
Date emergency contraception was used
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When did you first notice side effects?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which side effects did you experience? (Select all that apply)
*
Nausea
Vomiting
Abdominal pain
Headache
Dizziness
Fatigue
Menstrual changes
Other
How would you rate the severity of your side effects?
*
Mild
Moderate
Severe
Would you like someone to follow up with you about your report?
*
Yes, please contact me
No follow-up needed
Submit Report
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