-The patient is sexually active and desires birth control.
-Age of menarche:_____
-She is having regular menstrual periods with no cramps.
-Periods occur about every 28 days or 1 month.
-The average length of each period (in days):_______
-Menstrual flow is moderate, not scant or heavy and is not painful.
-Previous birth control use (including condoms): ________
-Previous use of emergency contraception (such as plan B): None
-Previous pregnancies: Never been pregnant before.
-Previous abortions or miscarriages: None
-She doesn’t think she is pregnant.
-First day of LMP:____
-Patient has had unprotected sex (without condoms or other birth control) since her last period.
-Last Pap smear (Date and results):
-History of STIs: None
–Birth control questionnaire reviewed.
–Pertinent negatives: Patient denies hx of smoking, migraines with aura, hypertension, blood clots (in self or first degree relatives), stroke or paralysis, liver tumor or problems, gallbladder problems, breast cancer, cervical cancer, severe headaches with blurred vision, nausea, or dizziness, gestational trophoblastic disease, infection of the tubes, ovaries, or uterus, female or abdominal surgery, abnormal pap smear, distorted uterine cavity, systemic lupus erythematosus (SLE), organ transplant, diabetes, heart disease.
