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New York State Department of Health

Contraception: Self-Screening Patient Intake Form[cite: 1]

SECURE ENCRYPTED ARCHIVE MODE [HIPAA COMPLIANT]
Date (mm/dd/yyyy): Date of Birth (mm/dd/yyyy): Age:
Legal Name: Name:
Gender:
Street Address:
City: State: ZIP Code:
Phone: () E-mail Address:
I have a Primary Care Provider:    Primary Care Provider:
Phone: () Fax: () Do you want info sent to your PCP?
Do you have health insurance?    Insurance Provider Name:
Ins ID #: Ins Group #: PCN #: Ins BIN #:
Allergies to medications?    If yes, list:
Allergies to food (ex. Soy, lactose)?    If yes, list:
By signing at the end of this questionnaire, you are attesting that: Information is true/accurate; False responses could lead to unintended health consequences; You are here voluntarily; You will consult a provider if you have questions; Medication is to prevent pregnancy[cite: 1].
Do you think you are pregnant or there is a chance you could be pregnant? [cite: 1]
Background Information[cite: 1]
1. Previously had a contraceptive dispensed by a pharmacist?    Last time:
2. Seen a provider (Physician, Nurse, Midwife) concerning reproductive/sexual health?    Last visit:
Contraception History[cite: 1]
3. Advised you should not take hormones or hormonal contraception?    Reason:
4. Ever used any form of hormonal contraception (tablet, patch, ring, shot)?
5. Experienced a bad reaction to using hormonal contraception?    Reaction:
6. Currently using any method of birth control (pill, patch, ring, shot)?    Which one:
7. Preferred method:
Medical Screening Questions (1 to 34)[cite: 1]
8. Baby < 6 months, nearly all meals breast/chest fed, AND no menstrual period since delivery?
9. Had a baby in the last 6 weeks?
10. Miscarriage or abortion in the last 7 days?
11. Last menstrual period started within the past 7 days?
12. Abstained from sexual intercourse since last menstrual period or delivery?
13. Using a reliable contraceptive method consistently and correctly?
14. First day of last menstrual period?
15. Recent change in vaginal bleeding that worries you?
16. Given birth within the past 21 days?    How long ago:
17. Currently breastfeeding?
18. Use tobacco products?
19. Have diabetes?
20. Get migraine headaches?    Warning signs (flashes of light, blind spots, tingling)?
21. Treated for inflammatory bowel disease?
22. High blood pressure, hypertension, or high cholesterol (even if controlled)?
23. Ever had a heart attack or stroke, or told you had heart disease?
24. Ever had a blood clot?
25. Told by healthcare professional that you are at risk of developing a blood clot?
26. Recent major surgery or planning surgery in the next 4 weeks?
27. Immobile for a long period (e.g., long airplane trip)?
28. Bariatric surgery or stomach reduction surgery?
29. Have or have ever had breast cancer?
30. Organ transplant?
31. Hepatitis, liver disease, liver cancer, gall bladder disease, or jaundice?
32. Lupus, rheumatoid arthritis, or any blood disorders?
33. Take medication for seizures, TB, fungal infections, or HIV?    List:
34. Other medical problems or take medications, including herbs/supplements?    List:
Patient Signature: Date: [cite: 1]
Pharmacist Use Only[cite: 1]
1. Blood Pressure Reading: / mmHg 2. Height: Weight: BMI: *(Patch: BMI<30 & wt<200lbs)*[cite: 1]
3. If dispensed - Drug: Directions: Quantity:
4. Healthcare Provider contacted/notified: (Date: ) [cite: 1]
5. If not dispensed, reason(s) for referral: [cite: 1]
Pharmacist Signature: Date: [cite: 1]