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EMERGENCY HORMONAL CONTRACEPTION PROFORMA Pharmacy Stamp CLIENT NAME DATE DOB AGE If 13, 14, 15 YEARS OLD EXPLAIN CONFIDENTIALITY AND LIMITS Who are with her? Who knows she is here? How old is partner?
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How to fill out emergency hormonal contraception proforma

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How to fill out emergency hormonal contraception proforma:

01
Firstly, gather all the necessary information such as the patient's personal details (name, age, contact information) and relevant medical history (including any allergies, current medications, and past use of hormonal contraceptives).
02
Next, identify the reason for needing emergency hormonal contraception (such as unprotected sex or contraceptive failure) and document it on the proforma.
03
Specify the date and time of the emergency contraception administration or prescription.
04
Evaluate and record the patient's eligibility and qualifications for emergency hormonal contraception based on established guidelines and protocols. This may include considerations such as the timing of intercourse, age restrictions, and certain medical conditions.
05
Document the type of emergency hormonal contraception recommended or provided to the patient. This can include the specific brand name or generic name of the medication (e.g. levonorgestrel), dosage instructions, and potential side effects or precautions.
06
Provide instructions on how to take the emergency hormonal contraception, emphasizing the importance of following the prescribed dosage and timing.
07
Advise the patient on the potential need for further contraceptive methods or counseling to prevent future unwanted pregnancies.
08
Confirm the patient's understanding of the given instructions and address any questions or concerns they may have.

Who needs emergency hormonal contraception proforma:

01
Individuals who have engaged in unprotected sexual intercourse without using any form of contraception.
02
Individuals who have experienced contraceptive failure, such as a condom breaking or a diaphragm slipping out of place.
03
Victims of sexual assault or abuse who require immediate access to emergency contraception.
04
Patients who have missed taking one or more doses of their regular hormonal contraceptive birth control method.
05
Those individuals who are not currently using any form of contraception and wish to prevent an unintended pregnancy following a recent sexual encounter.
It is essential to consult a healthcare professional or pharmacist to ensure the proper and effective use of emergency hormonal contraception.
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Emergency hormonal contraception proforma is a form used to document the provision of emergency contraception to individuals.
Healthcare providers who administer emergency hormonal contraception are required to file the proforma.
The proforma must be filled out with details of the patient, date and time of administration, type of emergency contraception provided, and any relevant medical information.
The purpose of the proforma is to ensure proper documentation of emergency contraception provided to patients.
Details of the patient, date and time of administration, type of emergency contraception provided, and any relevant medical information.
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