S: CC : HPI: Current/Past Birth Control Methods: Relationship: Sexually Active/#, New Partners/STI prevention: LMP: Regular/Irregular occurring every _____ days x ____days with light/moderate/heavy flow. Dysmenorrhea: Yes/No BTB: Yes/No Dyspareunia: Yes/No: Pap/Results: Vaginal Infections: Tobacco Use: Acne: Age: History of DVT/PE/Liver disease/CVA/HTN/Migraines with aura/Cancer/BF/DM: Yes/No O: Urine hCG test: Pap/Swab: A/P: Contraceptive- no absolute contraindications/no relative contraindications Patient prefers: Rx given x ____ months Education/Counseling Re: -Options/Benefits/Risk: COC, Patch, Nuva Ring, POP, Depo-Provera, IUD (Paraguard, Mirena, Skyla), Implanon Sunday start, missed pills, use condoms consistently to protect against STIs Family Planning: start folic acid 800 mcg with Vit D3, 3 months prior to stopping contraception when ready to conceive FU in 4 months if s/e or concerns
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