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CONTRACEPTIVES:
Have you ever used oral contraceptives? ____________________________________ Yes No If you answered yes, to using oral contraceptives, please answer the following questions. Oral Contraceptive Used? Date Started: Date Stopped? Oral Contraceptive Used? Date Started: Date Stopped? Oral Contraceptive Used? Date Started: Date Stopped? Oral Contraceptive Used? Date Started: Date Stopped? Did you have any problems using oral contraceptives? ____________________________________ Yes No If yes, please describe any problem: Contraceptive history The case history is essential for correct diagnosis and proper case management. When did you first have intercourse? ____________________________________ How old were you? ____________________________________ What do you understand about intercourse? ____________________________________ How do you feel? Are you sexually active? ____________________________________ What method of contraception are you currently using? ____________________________________ When did you start it? ____________________________________ Did you have any side effects? ____________________________________ What contraceptive methods have you tried previously? ____________________________________ When did you start using that contraceptive method? ____________________________________ Where did you procure it? ____________________________________ Why did you stop it? ____________________________________ With how many different people have you had intercourse up to now? ____________________________________ How many times have you had intercourse up to now? ____________________________________ What was the location? ____________________________________ Were you raped? ____________________________________ Have you ever been raped? ____________________________________ Where you ever molested? ____________________________________ What do you think is the difference between rape and molestation? ____________________________________ What is your normal day like? ____________________________________ |