| |
|
|
| Please ask the client all of
these questions: |
Check the correct
box: |
| 1. Is your period late and
do you think you could be pregnant now? |
Yes |
No |
| 2. Are you currently
breastfeeding a baby under 6 months of age? |
Yes |
No |
| 3. Do you smoke cigarettes AND
are you over 35 years of age? |
Yes |
No |
| 4. Do you have frequent and
very severe headaches that cause you problems; for example, blurred vision or
temporary loss of vision, which you get during the headache? |
Yes |
No |
| 5. Do you have high blood
pressure? |
Yes |
No |
| 6. Have you ever had a stroke,
blood clot in your legs or lungs, or a heart attack? |
Yes |
No |
| 7. Do you have diabetes (sugar
in your blood)? |
Yes |
No |
| 8. Do you have or have you
had breast cancer? |
Yes |
No |
| 9. Do you have a serious liver
disease or jaundice (yellow skin or eyes)? |
Yes |
No |
| 10. Do you regularly take any
pills for tuberculosis (TB), fungal infections or seizures (fits)? |
Yes |
No |
| If the client
answers YES to any of the above questions, refer her to the clinic/physician, and
give her condoms and/or spermicide to use in the meantime. If the client answers NO to all
the above questions, continue with the questions below. |
| 11. Do you have bleeding between
menstrual periods which is unusual for you, or bleeding after intercourse (sex)?
|
Yes |
No |
| (If the client
answers YES, she can use COCs, but refer her to the clinic/physician for further
evaluation of bleeding. Continue with question 12. |
| If the client
answers NO to all the questions, she can use COCs, but to find out when she can start,
ask: |
| 12. How many days ago did you
start your last menstrual period? |
|
_________ # days |
| If the client
began her last menstrual period within the past 7 days, she may begin COCs now. |
If the client
began her last menstrual period more than 7 days ago, and if:
- she has been using an effective method of contraception
(including abstinence), give her COCs, instruct her to begin taking them now, and instruct
her that she must use condoms and/or spermicides or abstinence for the next 7 days. Give
her condoms and/or spermicides.
- she has not been using an effective method of
contraception (including abstinence), give her the COCs but instruct her to start using
them on the first day or during the first 7 days of her next menstrual period. Give
her condoms and/or spermicide to use in the meantime.
|
