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Contraceptive Form
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First Name
*
Last Name
*
Email Address
*
When last did you have your period ?
Year
Month
Day
Phone Number
*
ID or Passport number ?
*
How many cigarettes do you smoke per day?
*
Select
Are You Pregnant Or BreastFeeding?
*
Select
Do you have any of the following Illnesses?
*
None
Stroke or heart attack
Liver disease
Gallbladder disease
High blood pressure (incl. during pregnancy)
Severe Headaches more than once a week
Cancer
Family History Of Breast Cancer
Diabetes
Bariatric surgery
Inflammatory bowel disease (Crohn's or ulcerative colitis)
Breast cancer
Organ transplantation
Lupus (SLE)
Thyroids
Migraine with an aura
Have you had any of the following related to blood clots?
*
None
Previous blood clots
Blood clotting disorder
Prolonged bed rest
Unable to move a limb
Any blood clotting medication
Do you take any of these medications?
*
None
St. John's Wort
TB treatment
Phenytoin
Oxcarbazepine
Carbamazepine
Barbiturates
Primidone
Topiramate
Seizure medication
HIV treatment
Oral fungal treatment
Lamotrigine
Do you have any medical history we need to be aware of ?
Do you have any allergies ?
*
Have you used contraceptives before ? Which type of contraceptive was it ?
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