Birth Control Screening Form

Patients will complete this form to self-screen for contraindications to contraceptives.

Our basic contraception self-screener is a 1 page form that collects the information necessary to assess medical eligibility for safe contraceptive use, ideal for efficient patient assessment. For a more comprehensive reproductive health encounter, our enhanced form incorporates best practices and recommendations to provide quality reproductive health care.

Log in below or sign up for a free Birth Control Pharmacist account to access this valuable resource.