Contraception Blank

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
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

Result - Copy and paste this output:

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