Pre-Screening Evaluation | Contraceptive Health Solutions

Your E-mail address

1. Enter your date of birth

2. What is your current height?

3. What is your current weight (in pounds)?

4. Do you have any allergies to medications?

Yes No

5. What age were you when you had your first period?

Yes No

7. On average, how long does your period last?

1-2 days
3-5 days
6+ days

8. When was your first day of your last menstrual period?

9. Are you currently utilizing a birth control method?
Birth control pill
Birth control patch
Ring
Injection
IUD
Implant
Other

None

10. Have you ever taken birth control pills, or used any of these birth control methods in the past?

11. Do you smoke cigarettes?

Yes No

How many cigarettes do you smoke per day?

More than 15 Less than 15

Yes No

13. What was your most recent blood pressure

15. Are you currently pregnant?

Yes No

16. Have you given birth within the past 42 days?

Yes No

17. On what date did you give birth?

18. Are you currently breastfeeding?

Yes No

With or without aura?

With Aura
Without Aura

20. Do you have diabetes?

Yes No

21. Do you have any of the following diabetic complications?

Nephropathy
Retinopathy
Neuropathy
Diabetes for longer than 20 years
Other vascular disease
None

22. Have you had any trauma, surgery, or immobilization within the last three months?

Yes No

24. Do you have a history of gallbladder disease?

Yes No

Currently Symptomatic
Medically Treated
Currently Asymptomatic
Treated by Cholecystectomy

25. Do you take any of the following medications or supplements?
Fosamprenavir (FPV)
Lamotrigine
Rifampin or Rifabutin
Certain Anticonvulsants
None

Yes No

27. Please provide the contact information for your primary healthcare provider

29. What medication are you requesting at this time?

You must answer this question in order for us to process your request. If you can't answer, please proceed with the Telemedicine on your Time survey

30. Looking for a natural approach or back-up contraceptives? Most insurance providers cover barrier methods and emergency contraceptives. Would you like to try any of the following additional methods?

Caya - One-size-fits-most Diaphragm
FC2 - Female condoms
Emergency Contraceptives

Yes No