SHC - WC Bc1.Previsit - Questionnaire 2
SHC - WC Bc1.Previsit - Questionnaire 2
SHC - WC Bc1.Previsit - Questionnaire 2
Instructions
If you are interested in starting or renewing birth control at the University of Mary Washingtons Student Health
Center (SHC), please do the following:
Questions
Your Name:
1. How old are you? _______
2. If you are sexually active, at what age did you have your first intercourse? ___________ N/A
3. What type of birth control would you like the SHC to help you with? Choose one:
Birth control pills Birth control patch (OrthoEvra) Vaginal ring (NuvaRing)
Injection (DepoProvera) Diaphragm IUD Mirena Other __________________
4. Have you ever used any type of birth control before, including condoms? No Yes
If yes, please explain: ________________________________________________________________________
5. Have you ever had problems using birth control in the past? No Yes
If yes, please explain: ________________________________________________________________________
6. Do you have or have you ever had any of the following medical conditions?
Heart disease Blood clots High blood pressure Gallbladder problems
Diabetes Chest pain Liver problems
If yes, please explain: ________________________________________________________________________
7. Has a close relative ever had unexplained blood clots in the legs or lungs? No Yes
If yes, please explain: ________________________________________________________________________
8. Do you have or have ever had breast cancer? No Yes
If yes, please explain: ________________________________________________________________________
9. Do you often get severe headaches with blurred vision, nausea or dizziness? No Yes
If yes, please explain: ________________________________________________________________________
10. Do you smoke cigarettes? No Yes
If yes, how many per day? ____________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Signature: _______________________________________________ (sign before mailing or at the time of your visit if emailed)
A nurse will contact you in 1-2 business days. How would you like to be contacted?
Call me Text me Phone Number: ___________________________
If you prefer texting, we need to know your phone provider:
AT&T Verizon Sprint Nextel T-Mobile Boost Mobile Other ______________________