FAMILY PLANNING (FP) FORM 1 Type of Cent New Accept Reasonfor FP: C spacing Cimtng Caters Metid curently ved (or Changing Mea} Co curert User coc = ND Ceowcwm = LAW ‘Dchangig Metod Reason: matical condition sitet GPP = Dinenel «BB Cotes (O.Charing Circ Dinette CO PostPatun STH spect [ODrpow Restart ‘Dimple Contam sow 1. MEDICAL HISTORY IV.__ RISKS FOR VIOLENCE AGAINST WOMEN (VAW) Does the cere any cf re folowing? "= rplssntelatorship ith pater Dyes ON 1 severe neatectes irae Caves No | = parnerdoesnctappove ote vstioFP dnc Ces No * hia of skeet atack hypertension ves No | = ison dometic vere or YAW es No 1 noptreunaihensiona/eqen bing orgumbleeirg Yes No | Refered ic: OSH * caent thsi of breast cancer breast mass ves Oo oweru * severe ces pin ves No CONGOs * cough ormare than 4 dys es ONo ote (spect ) = junce (Dyes No | V._ PHYSICAL EXAMINATION * nein vail beeing ves No | Woah 6 Bod presse: mn = atnomma vagha dschage ves No | Heigt Prise rte: iin 1 inthe of phenbmtil en-sizwre) cr ampicn(t-T8) ves OND | SKIN EXTREMITIES *sthecent a SMOKER? ves No | Crema Drommal = Win Osabiy? ves No | Opale ede (YES pease specie) yelowsh vaicnsies OBSTETRICAL HISTORY ‘Dera PELVIC EXAMINATION Nomber of pregnancies: P___ (CONJUNCTIVA: (Fer IUDAcompars) = Fultem __ Premature ‘Otoma rornal Arion, __ ving tidren hale mass Date fiat every _ es Dyetowsh (Dabroma dsctarge Typecast delve vagina Cossrean Scion NECK: Coercalarormaes Lsstmensipeiod | ‘Dromal Dinars Proious mensua period —__/__L Greckmass Dips orost Mersin fow ‘Derlarges yh noses Cinfaeaton or oxion ‘scanty (1-2 per day) BREAST: bendy discharge ‘Cedert (3-5 pds per day) ‘Crema (oer cansistercy hear 5 perp ay) mass Dim Osh Doysmenores rie discharge ceric endeess 1 Hyatrm moe (tinh last 2 mors) ‘ABDOMEN Cladnera mass tendemess Het of ca pregnay. ‘Drama utr paston: TI RISKS FOR SEXUALLY TRANSMITTED INFECTIONS, {Debeominal mass Dis Does the centr he cans parte have ay of flowng? vetonies Catone nama discharge from he genital area es Oho Diretotered {TYES' please indicate tom: CWVagira Peis Caen dept _em = sxrescrudcersin the genta area [aves No | ACKNOWLEDGEMENT: * painorburing sensation inthe genital ar Dives No | This i cer ha the PrsicanNuseie ofthe circ has fly 1 istry of eater or seuaytansmited ves No | exes to me the cferet metods aalbein family planing ard | lets frdychooehe etd 1 HIV ADS / etc intamatoy diese Des Oho ier Senate Dae For WRA blow 1B ys. 0 art Pg tug UO ated TL = Blair NSY= Anak! | INE consent aap the Famiy Paring ey 00 = Cntr cca POP= Pes s LAM= Lx ania | med SO Sars ma BT = Spr: BOM = ont mo N= Canad ‘mcs mtg STM Sth th — =SIDEB FP FORM 1 Medical cbsenaton, compas complication ence rendered procefures,aberaoy| ‘ezarinaon,teament nd refers) How tobe Reasonably Sure a Client is Not Pregnant 1. Did you have abay ess than sit) months ago are you fly oneal reateedig, and have you Dyes Ne had no menstrual period snce hen? 2. Have you abstained rom sen nercours since you last mens period or vey? Dyes OW ‘3. Have youhada baby inthe last four (4) weeks? Dyes ON 4. Did yourlast menstrual period start win the past seven (7) days? Dyes GN 5, Have you hada miscarigeorabortn ine las even 7} ys? Dyes No 6. Have you been using areal contraceptive metas consistently and corecty? Dyes ON ‘ifthe der answereé YES o atleast on ofthe questions and shes te signs cr symptoms of pregnancy, provide cent wth desired method, ‘te et answered NO ol of he cua oramancy tara ha nied Tha let che acs mance es resonant