Must be filled in completely except sections in (parentheses) which are optional. Please print legibly.

NAME:
DATE OF BIRTH (must be 14 or older):
(SOCIAL SECURITY NUMBER):
MAILING ADDRESS: STREET AND NUMBER
CITY
STATE(only available in Hawaii)
ZIP:

(E-MAIL ADDRESS):

HEIGHT:
WEIGHT:
YOUR IDEAL WEIGHT:
COMPLEXION PROBLEMS ?:

AGE WHEN YOUR MENSTRUAL PERIODS BEGAN:
LENGTH OF TIME FROM THE FIRST DAY OF ONE PERIOD TO THE FIRST DAY OF THE NEXT:
NUMBER OF DAYS OF FLOW:
AMOUNT OF FLOW:
PAIN OR OTHER DISCOMFORT:
FIRST DAY OF YOUR LAST PERIOD:
FIRST DAY OF THE PREVIOUS PERIOD:

NUMBER OF PREGNANCIES:
NUMBER OF DELIVERIES:
NUMBER OF MISCARRIAGES:
NUMBER OF ABORTIONS:
COMPLICATIONS OF PREGNANCY:

DATE OF LAST PAP SMEAR:
ANY ABNORMAL PAP SMEARS? IF YES, GIVE DETAILS.
ANY STD, INCLUDING CHLAMYDIA, GONORRHEA, HERPES, WARTS? IF YES, GIVE DETAILS
WHICH BIRTH CONTROL METHODS HAVE YOU USED?

IF YOU HAVE EVER BEEN ON BIRTH CONTROL PILLS, PLEASE GIVE THE NAME (OR WHAT THE PILL OR PACKAGE LOOKED LIKE). DID YOU HAVE ANY PROBLEMS ON THEM?

OPERATIONS YOU HAVE HAD:

MEDICAL PROBLEMS, NOW OR PREVIOUSLY:

AMOUNT OF CIGARETTE SMOKING:
FOR HOW LONG?

ALLERGIES TO MEDICATION:

MEDICATIONS YOU CURRENTLY TAKE:

HAVE YOU EVER HAD HIGH BLOOD PRESSURE, DIABETES, HEPATITIS, MIGRAINE HEADACHES OR BLOOD CLOTS? IF YES, PLEASE GIVE DETAILS.

ANYONE IN YOUR FAMILY WITH HIGH BLOOD PRESSURE, DIABETES OR MIGRAINE HEADACHES? INDICATE WHO HAS WHAT, AND WHAT TREATMENT THEY ARE ON.

ALL OF THIS INFORMATION IS THE TRUTH.

I WILL READ THE COMPLETE PACKAGE INSERT THAT COMES WITH THE PILLS.

SIGNED:___________________________________________ DATE: