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.