NAME:________________________________________FHC ID #____________________CLASS_________DATE_________________

CC:_____________________________________________________________________________________________________

________________________________________________________________________________________________________
 

HISTORY	YES	NO	COMMENTS
Do you smoke?			_____________ppd
Condom use?			LMP
Satisfied with method?
Last Depo. Inj.			Date: Within 12 wks Yes No

Questions or concerns ?

 

SYMPTOMS	YES	NO	DESCRIBE
Abdominal Pain
Chest pain (Severe)Cough, SOB
Headache (Severe) dizziness, weakess, numbness
Eye Problems (vision loss or loss of vision)
Severe leg pain or swelling in calf or thigh
Prolonged very heavy bleeding
Nausea
Spotting between periods
Skin changes/discolorations
Anxiety or depression
Other

 

O:

Current Wt.	Wt at last Depo visit
BP ___________/__________	BP at last Depo visit _____________/______________

Additional P.E.:_____________________________________________________________________________________________________

A: Exam WNL Other ______________________________________________________________________

P: Depo Provera 150 mg. IM __________________________site given. Lot #_________________Exp. Date._____________

Told to wait 30 mins. after injection in HC RTC 11 weeks______________________

Depo not given. Reason______________
 

Date / /