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Oral Contraceptive Eligibility Screening
Please complete this screening to determine if you are eligible to start oral contraceptives. Your information will be kept confidential.
Date of Birth
*
Do you currently smoke?
*
A
Yes
B
No
Have you ever been diagnosed with any of the following?
*
High blood pressure
History of blood clots (DVT or PE)
Migraines with aura
None of the above
Are you currently pregnant or trying to conceive?
*
A
Yes
B
No
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