Edit Health History

1. Enter your date of birth

2. What is your current height?

3. What is your current weight (in pounds)?

4. Do you have any allergies to medications?

Yes

5. What age were you when you had your first period?

6. Do you have regular menstrual cycles?

Yes

7. On average, how long does your period last?

1-2 days

3-5 days

6+ days

8. When was your first day of your last menstrual period?

9. Are you currently utilizing a birth control method?

Birth control pill

Birth control patch

Ring

Injection

IUD

Implant

Other

None

10. Have you ever taken birth control pills, or used any of these birth control methods in the past?

Birth control pill

Birth control patch

Ring

Injection

IUD

Implant

Other

None

11. Do you smoke cigarettes?

Yes

How many cigarettes do you smoke per day?

More than 15

Less than 15

12. Do you have high blood pressure or hypertension?

Yes

13. What was your most recent blood pressure

15. Are you currently pregnant?

Yes

16. Have you given birth within the past 42 days?

Yes

16(a). On what date did you give birth?

16(b). Are you currently breastfeeding?

Yes

17. Are you regularly prone to migraines?

Yes

With or without aura?

With Aura

Without Aura

18. Do you have diabetes?

Yes

18(a). Do you have any of the following diabetic complications?

Nephropathy

Retinopathy

Neuropathy

required Diabetes for longer than 20 years

Other vascular disease

None

19. Have you had any trauma, surgery, or immobilization within the last three months?

Yes

21. Do you have a history of gallbladder disease?

Yes

Currently Symptomatic

Medically Treated

Currently Asymptomatic

Treated by Cholecystectomy

22. Do you take any of the following medications or supplements?

Fosamprenavir (FPV)

Lamotrigine

Rifampin or Rifabutin

Certain Anticonvulsants

None

23. Would you like for us to send new prescription information to your primary healthcare provider?

Yes

Name

Address

City

Zip

Company

Fax

24. What medication are you requesting at this time?

You must answer this question in order for us to process your request. If you can't answer, please proceed with the Telemedicine on your Time survey

25. Other than pregnancy prevention, are you looking to get additional benefits from a hormonal contraceptive?

Regulate Acne

Regulate Cramps and Period

Minimal Side Effects

Skip Periods

Regulate PMS

26. Looking for a natural approach or back-up contraceptives? Most insurance providers cover barrier methods and emergency contraceptives. Would you like to try any of the following additional methods?

Caya - One-size-fits-most Diaphragm

FC2 - Female condoms

Emergency Contraceptives

*You must answer

26(a): Caya is a one-size-fits-most diaphragm that can be used for up to 2 years before having to replace it with a new one. It can be used alone or paired with other methods to significantly decrease your risk of pregnancy. There are a few reasons why Caya may not be a good option for you. Please select from below if you have any of the following contraindications:

I am not familiar enough with my body to find my cervix and identify the space between the front of my cervix and the inside of my pubic bone or I am unable to follow instructions on how to insert the Caya device to make sure it fits appropriately

I have given birth in the past 6 weeks

I have previously been fitted for or used a diaphragm of size 60 mm or size 85 mm or larger

I have acute or chronic-recurrent urinary tract infections

I currently have an infection in my vagina, cervix, or pelvis

I have pelvic floor weakness that leads to incontinence (inability to control urination) or changes the location of my vagina and/or uterus (such as prolapse)

I have a cystocele (a bulge of my bladder into my vagina)

I do not have a well formed retropubic niche (there is not enough space between the front of my cervix and my pubic bone to fit the tip of a finger)

I have a retroverted uterus (my uterus tilts backward rather than forward)

None

27. Would you like to include generic options?

Yes

28. How would you best describe yourself?

African/ African American

East Asian

Native American

Pacific Islander

White/ Caucasian

Central or South American

Indian

Bi-racial (two or more races)