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CONTRACEPTIVE HISTORY FORM Name Birthdate This section to be completed by patient: Please fill in the blank or circle your answer. Name of current contraceptive: Length of time it has been used? Do
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How to fill out contraceptive history form

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How to fill out a contraceptive history form:

01
Start by providing personal information such as your full name, date of birth, and contact details.
02
Next, indicate your current medical provider and any previous providers you have seen for reproductive health issues.
03
Specify your contraceptive history by detailing the different methods you have used in the past, including the duration and any side effects experienced.
04
If you have had any pregnancies, indicate the number of pregnancies, deliveries, and any complications or outcomes.
05
Provide information on any sexually transmitted infections (STIs) you have had, including the type of infection, treatment received, and current status.
06
Mention any significant health conditions or medical history that may impact your contraceptive choices, such as blood clotting disorders or hormonal imbalances.
07
If you have any concerns or preferences regarding contraceptive options, make sure to communicate them clearly on the form.
08
Lastly, review the completed form for accuracy and ensure that all necessary sections have been filled out.

Who needs a contraceptive history form:

01
Women who are seeking contraceptive methods or considering changes in their current method may be required to fill out a contraceptive history form. This is typically done by healthcare providers offering reproductive health services.
02
Individuals who are undergoing a consultation for family planning purposes, such as couples planning for pregnancy or women seeking assistance in preventing pregnancy, may also need to provide their contraceptive history.
03
Teenagers or young adults who are visiting a healthcare professional regarding sexual health, contraception education, or women's health may be asked to complete a contraceptive history form as part of their assessment.
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Contraceptive history form is a document that gathers information about an individual's history of contraceptive use.
Anyone who has used contraceptives in the past or is currently using them may be required to file a contraceptive history form.
To fill out a contraceptive history form, provide accurate information about your contraceptive use, including types of contraceptives used and duration of use.
The purpose of contraceptive history form is to track and document an individual's history of contraceptive use for medical or research purposes.
Information that must be reported on contraceptive history form include types of contraceptives used, duration of use, any side effects experienced, and reasons for contraceptive use.
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