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CONTRACEPTIVES:

Have you ever used oral contraceptives?
____________________________________
Yes No
If you answered yes, to using oral contraceptives, please answer the following questions.
Oral Contraceptive Used? Date Started: Date Stopped?
Oral Contraceptive Used? Date Started: Date Stopped?
Oral Contraceptive Used? Date Started: Date Stopped?
Oral Contraceptive Used? Date Started: Date Stopped?

Did you have any problems using oral contraceptives?
____________________________________
Yes No
If yes, please describe any problem:

Contraceptive history

The case history is essential for correct diagnosis and proper case management.
When did you first have intercourse?
____________________________________
How old were you?
____________________________________
What do you understand about intercourse?
____________________________________
How do you feel?
Are you sexually active?
____________________________________
What method of contraception are you currently using?
____________________________________
When did you start it?
____________________________________
Did you have any side effects?
____________________________________
What contraceptive methods have you tried previously?
____________________________________
When did you start using that contraceptive method?
____________________________________
Where did you procure it?
____________________________________
Why did you stop it?
____________________________________
With how many different people have you had intercourse up to now?
____________________________________
How many times have you had intercourse up to now?
____________________________________
What was the location?
____________________________________
Were you raped?
____________________________________
Have you ever been raped?
____________________________________
Where you ever molested?
____________________________________
What do you think is the difference between rape and molestation?
____________________________________
What is your normal day like?
____________________________________