disease, such as those with a family history of eye disease, diabetes or high “Much like mammograms and diabetes screenings, regular eye exams will help …
NEICAC FAMILY PLANNING
MEDICAL HISTORY
Review of Systems
Name:________________________________________________________
Birthdate:_________________ Age:________
Last First
Initial
Reason for your visit
today:______________________________________________________________________
_____
Family Planning serves a wide range of women We have tried to make this
form as complete as possible, realizing that some questions will not apply
to every womans particular circumstances All information is strictly
confidential
CONTRACEPTIVE HISTORY
Check all birth control methods you have used: Pill DepoProvera
Lunelle IUD Condom Sterilization Diaphragm
Foam/Suppository Natural Family Planning Rhythm Withdrawal
Other_________________________________________
|YES |NO | |
| | |Do you or your partner use birth control now? |
| | |If yes, what methods do you use?_________________________ How long have |
| | |you used this
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