2. What is your current height?
4. Do you have any allergies to medications?
6. Do you have regular menstrual cycles? ?
7. On average, how long does your period last?
9. Are you currently utilizing a birth control method?
10. Have you ever taken birth control pills, or used any of these birth control methods in the past?
11. Do you smoke cigarettes?
How many cigarettes do you smoke per day?
12. Do you have high blood pressure or hypertension? ?
14. Have you experienced any of the following in the last week?
15. Are you currently pregnant?
16. Have you given birth within the past 42 days?
16(b). Are you currently breastfeeding?
17. Are you regularly prone to migraines? ?
With or without aura? ?
18. Do you have diabetes?
18(a). Do you have any of the following diabetic complications?
19. Have you had any trauma, surgery, or immobilization within the last three months?
20. Have you ever been diagnosed with any of the following?
21. Do you have a history of gallbladder disease?
22. Do you take any of the following medications or supplements?
23. Would you like for us to send new prescription information to your primary healthcare provider? ?
24. How long have you been utilizing a hormonal birth control method?
26. Other than pregnancy prevention, are you looking to get additional benefits from a hormonal contraceptive?
27. 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?
27(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:
28. Would you like to include generic options? ?
29. How would you best describe yourself? ?