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Contraception: Self-Screening Patient Intake Form

NYSDOH Form, Confidential, Protected Health Information

Birthday
Month
Day
Year
Sex Assigned at Birth
Gender Identification
Gender Identification
Multi-line address
I have a Primary Care Provider
Yes
No
Do you have health insurance
Yes
No
Do you have any food or drug allergies?
Yes
No

By signing at the end of this questionnaire, you are attesting that:

  • The information is true and accurate tot he best of your knowledge

  • False responses could lead to unintended health consequences

  • You are here voluntarily and you are not being coerced

  • If you still have questions or concerns, you will consult with a primary care provider or reproductive health care provider

  • I understand that the medication I am being dispensed is to be utilized to prevent pregnancy

Do you think you are pregnant or there is a chance you could be pregnant?
Yes
No
Have you previously had a contraceptive dispensed to you by a pharmacist?
Yes
No
Other than a pharmacist, have you seen a provider (i.e. Physician, Nurse, Midwife etc.) concerning your reproductive and/or sexual health?
Yes
No
Has a health care provider ever advised you that you should not take hormones or hormonal contraception?
Yes
No
Have you ever used any form of hormonal contraception including but not limited to birth control tablets, the patch, vaginal ring, or birth control shot/injection?
Yes
No
Did you have a baby less than 6 months ago, are nearly all your infant’s meals are breast/chest feedings, AND have you had no menstrual period since the delivery?
Yes
No
Have you had a baby in the last 6 weeks?
Yes
No
Did you have a miscarriage or abortion in the last 7 days?
Yes
No
Did your last menstrual period start within the past 7 days?
Yes
No
Have you abstained from sexual intercourse since your last menstrual period or delivery?
Yes
No
Have you been using a reliable contraceptive method consistently and correctly?
Yes
No
Have you had a recent change in vaginal bleeding that worries you?
Yes
No
Have you given birth within the past 21 days?
Yes
No
Are you currently breastfeeding?
Yes
No
Do you use tobacco products?
Yes
No
Do you have diabetes?
Yes
No
Do you get migraine headaches?
Yes
No
Are you being treated for inflammatory bowel disease?
Yes
No
Do you have high blood pressure, hypertension, or high cholesterol? (Please indicate yes, even if it is controlled by medication
Yes
No
Have you ever had a heart attack or stroke, or been told you had any heart disease?
Yes
No
Have you ever had a blood clot?
Yes
No
Have you ever been told by a healthcare professional that you are at risk of developing a blood clot?
Yes
No
Have you had recent major surgery or are you planning to have surgery in the next 4 weeks?
Yes
No
Will you be immobile for a long period? (e.g. flying on a long airplane trip, etc.)
Yes
No
Have you had bariatric surgery or stomach reduction surgery?
Yes
No
Do you have or have you ever had breast cancer?
Yes
No
Have you had an organ transplant?
Yes
No
Do you have or have you ever had hepatitis, liver disease, liver cancer, or gall bladder disease, or do you have jaundice (yellow skin or eyes)?
Yes
No
Do you have lupus, rheumatoid arthritis, or any blood disorders?
Yes
No
Do you take medication for seizures, tuberculosis (TB), fungal infections, or human immunodeficiency virus (HIV)?
Yes
No
Do you have any other medical problems or take any medications, including herbs or supplements?
Yes
No
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Thanks for completing the form! This form will be sent to Dr. Shawn, and he will alert the team to your request.

Bolton's Pharmacy, Inc.

p: 315-782-5961

f: 315-782-4496

info@boltonspharmacy.net

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