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VIRGINIA ROUTINE HORMONAL CONTRACEPTIVE SILK-SCREENING QUESTIONNAIRE Name: ___ Today's Date: ___ Weight: ___ Date of Birth: ___ Age: ___ Healthcare Providers Name: ___ Healthcare Providers Telephone,

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How to fill out hormonal contraceptive self-screening questionnaire

01

Obtain a copy of the hormonal contraceptive self-screening questionnaire.

02

Read each question carefully and provide honest and accurate answers.

03

Consult with a healthcare provider if you are unsure about how to answer any of the questions.

04

Submit the completed questionnaire to your healthcare provider for review and further guidance.

Who needs hormonal contraceptive self-screening questionnaire?

01

Individuals who are considering starting hormonal contraceptives.

02

Individuals who are currently using hormonal contraceptives and want to assess their risk factors.

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What is hormonal contraceptive self-screening questionnaire?

Hormonal contraceptive self-screening questionnaire is a form that individuals fill out to assess their suitability for using hormonal contraceptives.

Who is required to file hormonal contraceptive self-screening questionnaire?

Individuals who are considering using hormonal contraceptives are required to fill out the self-screening questionnaire.

How to fill out hormonal contraceptive self-screening questionnaire?

The questionnaire can be filled out by answering the questions honestly and providing accurate information about one's medical history.

What is the purpose of hormonal contraceptive self-screening questionnaire?

The purpose of the questionnaire is to ensure that individuals can safely use hormonal contraceptives without risk to their health.

What information must be reported on hormonal contraceptive self-screening questionnaire?

Information such as medical history, current medications, allergies, and health conditions must be reported on the questionnaire.

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