Subjective/History Elements
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[comment memo="Use for women starting or continuing contraception"]
[text size="3"] yo G[text size="2"] P[text size="2"] with LMP of [text size="10"] here to discuss contraception.
-For contraception, currently using: [checkbox value="Condoms|Withdrawal method|Calendar method (timing intercourse around ovulation)|Birth control pills|Birth control patch (OrthoEvra)|Vaginal ring (NuvaRing)|Injection (DepoProvera)|Diaphragm|Nexplanon|Mirena|Other-"] [text size="20"]
-She is currently interested in: [checkbox value="Birth control pills|Birth control patch (OrthoEvra)|Vaginal ring (NuvaRing)|Injection (DepoProvera)|Diaphragm|Nexplanon|Mirena|Other-"] [text size="20"]
-She has previously used: [checkbox value="Condoms|Withdrawal method|Calendar method (timing intercourse around ovulation)|Birth control pills|Birth control patch (OrthoEvra)|Vaginal ring (NuvaRing)|Injection (DepoProvera)|Diaphragm|Nexplanon|Mirena|Other-"] [text size="20"]
-Problems with prior contraception methods? [select value="No problems|The following problems-"] [text size="50"]
-Patient identified reasons for seeking/using contraception: [checkbox value="prevent pregnancy|irregular menses|acne|severe menstrual pain|heavy menstrual bleeding|other-"] [text size="50"]
-How soon patient desires to attempt to conceive: [text size="5"] [select value="never|year(s)|month(s)"]
-Age of menarche? [select value="|N/A"][text size="3"]
-Sexually active? [select name="Sex" value="no|Yes"][conditional field="Sex" condition="(Sex).is('Yes')"]
-Number of sexual partners in past year *[text size="3"]*[/conditional]
-Age of first intercourse? [select value="|N/A"][text size="3"]
-Reports the following contraindications for contraception: [checkbox value="NONE|Heart disease|Blood clots|High blood pressure|gallbladder problems|Diabetes|Chest pain|Liver problems|Close relative with blood clots in legs/lungs|hx of breast cancer|hx of severe HAs/migraines|smokes/chews/vapes"] [text size="50"]
-Recent pregnancy in the past month? [select value="No|Yes"]
-Unprotected sex (without a condom or other birth control) since last period? [select name="Sex" value="No|YES"]
[conditional field="Sex" condition="(Sex).is('YES')"] Approximate date of unprotected sex - [text size="10"][/conditional]
-Prior Pap? [select name="Pap" value="No|Yes"][conditional field="Pap" condition="(Pap).is('Yes')"] Month/year- [text size="10"]; Results- [text size="20"][/conditional]
[comment memo="For use in CRDAMC FM clinic"]
Use for women starting or continuing contraception
yo G P with LMP of here to discuss contraception.
-For contraception, currently using:
-She is currently interested in:
-She has previously used:
-Problems with prior contraception methods?
-Patient identified reasons for seeking/using contraception:
-How soon patient desires to attempt to conceive:
-Age of menarche?
-Sexually active?
-Age of first intercourse?
-Reports the following contraindications for contraception:
-Recent pregnancy in the past month?
-Unprotected sex (without a condom or other birth control) since last period?

-Prior Pap?
For use in CRDAMC FM clinic

Result - Copy and paste this output: