Name ______________________________________FHC #________________Class________ Date_______________

S: CC ____________________________________________________________________________
 
 

Name of OC __________________________

LMP _________________________________

Hx:                                                             Yes             No         Description

Satisfied with method
Desires to continue
Abdominal pain
Chest pain
Cough
SOB
Headache
Dizziness (weak, numb)
Eye problems
Leg pain / calf swelling
Questions about method
other questions
Other

• BP __________/_________ Wt._____________________ U/A HCT

• Pill check WNL. May continue method Consult with NP

P:        Pill type ______________________ Lot # _________________________ Exp. date ____________
                # of packs given ________________ # of refills left __________________
 

RTC                       3 mos                   6 mos                         12 mos.                   Other
 

________________________________________________
Provider