Your First Name※Required
Your Last name※Required
Email Address※Required
Phone Number※Required
Date of Birth※Required
Postal Code※Required
Address※Required
【Common Questionnaire】
Recent menstrual period※Required
From... to around… Can't recall
Menstrual cycle※Required
Days between periods Irregular Don’t know
Please write down any questions you would like to ask during the examination.
【Low-dose Pill Consultation】
Have you ever used the pill?
First time Taken it before
What pills have you used so far?
Triquilar Marvelon Ange Favoir Labellefille Other
What is your reason for using the pill?
Do not want to get pregnant Irritability Feeling depressed Can't stand menstrual cramps Heavy periods Sporadic menstruation Acne skin problems Want to change the period date
Do you currently have any of the following symptoms ?
Uterine fibroids Endometriosis Uterine cancer Breast cancer Diabetes High blood pressure High cholesterol Heart disease Antiphospholipid antibody syndrome Migraine headache Cerebral infarction Varicose veins Liver dysfunction Jaundice Smoking more than 15 cigarettes a day Breastfeeding Pregnant None in particular
【After Pill Questionnaire】
First time Have you ever taken the pill?
Currently, how many hours have passed since intercourse?
Within 6 hours 12 hours or less 24hours or less 36hours or less 48hours or less 60hours or less 72hours or less More than 72 hours
【Questionnaire about thrombosis symptoms at the 3-month checkup】
What symptoms do you have?
Not drinking much water Swelling Shortness of breath Chest tightness Severe headache Dizziness Blurred vision Having trouble speaking Calf pain Loss of consciousness None of the above
