Health & Wellness Centre,
SL 270, Student Centre, UTSC
Please answer the following questions to guide which method is right for you.
What is the reason you are requesting a prescription for hormonal birth control?
birth control acne treatment cycle control other
Have you ever been sexually active?
yes no If yes for how long:
Have you ever had a pap test?
yes no date: results:
What do you currently do to prevent pregnancy? Describe:
Have you previously used hormonal contraception?
yes no which one: When did you last use this method?
Do you have any allergies?
yes no If yes, please list:
Are you taking any medications or herbal remedies?
yes no If yes, please list:
Do you use any tobacco?
yes no marijuana: yes no amount____ per day or per week
Do you have/ever had any mental health concerns or diagnosis?
yes no describe:
When was the first day of your last menstrual period?
Are you concerned you may be pregnant?
yes no
Do you, your parents, grandparents or siblings have or ever had any of the following health issues?
Blood clots in the legs/lungs/eyes or elsewhere:
yes no describe:
Stroke:
yes no describe: At what age did this occur:
Heart Attack or coronary disease:
yes no describe:
Cancer of the breast or sex organs:
yes no describe:
Unusual vaginal bleeding:
yes no describe:
Liver disease/jaundice or tumours:
yes no describe:
Partial or complete loss of vision caused by disease:
yes no describe:
Migraine headaches (with or without aura?):
yes no describe:
Diabetes: yes no Age when diagnosed and type:
High blood pressure: yes no describe:
Fibroids: yes no describe:
Which method of hormonal contraception do think you would like to start?
pill patch ring intrauterine system /device undecided
Please go to http://www.sexualityandu.ca/birth-control and review methods
I certify that I have completed this questionnaire to the best of my knowledge
__________________ _________________ ______________ _________
Student NAME Student NUMBER Signature Date
Hormonal Contraceptive Screening
Questionnaire
