Contraceptive Choices Questionnaire

Finding the Right Contraceptive for YOU

COMPLETE AND THEN PRINT OUT THIS INFORMATION SHEET AND USE IT AS YOU GO THROUGH THE OPTIONS AND/OR TAKE IT WITH YOU TO YOUR CAREGIVER ONCE YOU HAVE DECIDED ON A METHOD OF BIRTH CONTROL. THIS IS JUST FOR YOUR USE. YOU DON'T SEND IT ANYWHERE. SO PLEASE BE HONEST WITH YOURSELF.

DESCRIBE YOURSELF

Name

Age: Sex: Male Female

Height: Weight:

Are you under age 35?	Yes No
Do you have you children?	Yes No
Are you now pregnant?	Yes No

LIFESTYLE CHOICES

This will help you to evaluate the type of contraception you may need based on your lifestyle. The method you choose should be comfortable to use and fit in with your lifestyle. There are no right or wrong answers.

Do you have more than one sex partner? Yes No

How often do you have sexual intercourse?
At least 3-4 times per week At least 4-5 times per month

Do you ever have sex with a partner who you suspect may be at risk of being exposed to HIV (the AIDS virus)?
Yes No

Do you engage in anal intercourse? Yes No

If a birth control method, such as a diaphragm, cervical cap or condom, interrupts lovemaking, will you prefer not using it?
Yes, I would discontinue using it. No, I would still use it.

On a scale of 1 to 5 where 1 means you hate routines and 5 means you function best when you have a set routine, where would you place yourself?
1 2 3 4 5

In general, does learning that a contraceptive contains hormones make you more likely or less likely to use it, or does it make no difference?
Yes, it does make a difference No difference

Do you ever want to get pregnant? Yes No

If yes, give a time frame in months to years:

Do you smoke? Yes No

MEDICAL HISTORY

These questions reveal your medical history that could affect the choices you have in contraception. You will notice as you go through the different options, that some CANNOT be used by women with certain Medical Problems. This will help alert you to that. The list is detailed, but there are women who cannot use certain methods of birth control because of medical conditions. These questions do pertain mostly to women since, other than condoms and Natural Family Planning, they are the ones who must make choices about birth control options.

DO YOU NOW OR HAVE YOU EVER HAD ANY OF THE FOLLOWING MEDICAL CONDITIONS?

Yes No	Blood clots?
Yes No	High blood pressure?
Yes No	History of cluster headaches, migraine headaches, or unexplained headaches?
Yes No	Pelvic surgery and/or abdominal surgery?
Yes No	Abnormal pap smear?
Yes No	Problems with your liver?
Yes No	Gall Bladder disease?
Yes No	History of diabetes now or during a pregnancy?
Yes No	Abnormal vaginal bleeding?
Yes No	Pelvic Inflammatory Disease (PID)?
Yes No	Breast Cancer?
Yes No	Epilepsy or other seizure disorder?
Yes No	Sexually Transmitted Disease?
Yes No	Frequent Urinary Tract Infections?
Yes No	Frequent Vaginal Infections?
Yes No	Cervical dysplasia or cervical cancer?
Yes No	Tubal pregnancy?
Yes No	Allergies to latex?
Yes No	Allergies to Nonoxynol-9?
Yes No	Tuberculosis?
Yes No	Depression?
Yes No	Sickle Cell Disease?
Yes No	Uterine Fibroids?
Yes No	Meningioma?
Yes No	DES daughter? or Son?

FINALLY FINISHED !

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