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Family Medicine Specialist Template

Contraceptive History

A professional Family Medicine Specialist template for healthcare professionals.
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Specialty

Family Medicine Specialist

Used

102 times

Type

Note

Last edited

7/17/2025

Created by

Dornubari Lebari

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About this template

The Contraceptive History template is a comprehensive documentation tool designed for Family Medicine Specialists to efficiently record a patient's contraceptive needs and history. This template covers a wide range of topics including current contraception methods, menstrual history, pregnancy risk assessment, and relevant medical history. It is particularly useful for clinicians providing reproductive health services, ensuring all necessary information is captured for informed decision-making. The template is optimized for use with Heidi, an AI medical scribe, to streamline the documentation process and enhance patient care.

Preview template

Reason for attendance: Requires contraception Current contraception: None If problems with current/previous contraception, give details: Not applicable Last menstrual period: 2023-09-15 Was this a normal period for you? Yes Longest cycle length: 28 days Is there a risk of pregnancy? No Pregnancy test done in clinic? No Expiry date of test: 2024-01-01 Result of pregnancy test: Not applicable Is a repeat pregnancy test due? No When? Is there post-coital bleeding? No Is there intermenstrual bleeding? No Comments on menorrhagia or dysmenorrhoea: None Any current gynaecological symptoms or diagnosis? None Cervical screening? Up to date Obstetric history: Gravida 2, Para 2 Any history of molar pregnancies? No Date and outcome of last pregnancy: 2021-06-10, Full-term delivery Are you currently postpartum? More than 6 weeks Are you currently breastfeeding? No Medical history - any known medication or drug allergies? Penicillin Any history of cardiovascular disease? No Any history of hypertension? No Any personal history of thromboembolic disease or known thrombogenic mutations? None Any history of cerebrovascular disease? No Any history of migraine? No Any history of diabetes? No Any history of symptomatic gallbladder disease? No Any history of liver disease? No Any history of breast cancer? No Any history of genetic mutations associated with breast cancer? Unknown Any history of epilepsy? No Any history of antiphospholipid syndrome? No Any history or risk factors for osteoporosis? No Past surgical history: Appendectomy in 2015 Any planned surgery or recent surgery or prolonged immobilization? None Current list of medications: None Current use of recreational drugs? None Alcohol intake: Occasional Smoker or ex-smoker: Ex-smoker Smoking history: Quit in 2018, smoked for 5 years Family history of VTE in first-degree relative under the age of 45 years? No Any history of STIs? None Patient understands that STI screen is offered as standard part of reproductive service and is an opt-out option. Patient gives consent. Do you or have you ever felt frightened or unsafe in your relationship? No Weight: 68 kg Blood pressure: 120/80 mmHg General comments: Patient is in good health and seeking advice on starting contraception.

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