Name: ______

How did you first hear about Natural Family Planning? Please give specific name or program, where appropriate.

Priest ______Parish Bulletin ______

Marriage Prep Program ______Health Care Provider ______

NFP Publicity ______Other ______

Single _____ Married _____ Engaged _____ Date of Marriage or Wedding ______

 Woman: ______

Address: ______

City: ______State: ______Zip: ______

Work Phone: ______Home Phone: ______Occupation: ______

Race (optional): ______Religion (optional): ______

 Man: ______

Address: ______

City: ______State: ______Zip: ______

Work Phone: ______Home Phone: ______Occupation: ______

Race (optional): ______Religion (optional): ______

For Office Use Only

Group: ______

Date:

Initial Session: ______Woman ______Man ______

Second Session: ______Woman ______Man ______

Third Session: ______Woman ______Man ______

6-cycle Follow-up: ______Woman ______Man ______

12-cycle Follow-up: ______Woman ______Man ______

Payment Recd.: ______Date: ______Method of pmt. ______

Family Planning Intent/Interest in NFP

In the next calendar year, how do you intend to use NFP? _____ fertility awareness;

____ achieve pregnancy; ____ space pregnancy temporarily; ____ avoid pregnancy permanently

Please rank your top three reasons for choosing NFP as your family planning method.

_____ reproductive problems/medical issues _____ moral/religious motivation

_____ holistic/natural option _____ desire stronger relationship

_____ pre-menopause _____ breastfeeding

_____ dissatisfaction with current method _____ required to take

_____ other (please specify)

The following information is confidential and will be seen only by your instructor unless written permission is given to the Family Life Office.

Gynecological History

Date of birth: ______Year menses started: ______Date of last menses: ______

Length of menses: heavy flow days ______; medium flow days ______; spotting days ______

Length between menses: longest ______; shortest ______; usual ______

History of any menstrual problems, e.g., cramps, bleeding, etc.: ______

______

Date of last physical: ______Date of last Pap smear: ______

Have you ever had an abnormal Pap smear? ______If yes, please give the date, findings, and treatment: ______

No. of pregnancies: _____ Date(s) of miscarriage(s): ______

Date(s) of abortion(s): ______

Child(ren)’s names and dates of birth: ______

______

Are you nursing now? ______Age of child: _____ If no, did you receive medicine to dry the milk supply? ______

If yes, date of any bleeding/spotting since end of lochia: ______

If nursing, how many feedings day and night? _____ Longest interval between feedings? _____

Are you nursing a total of two or more hours per day? ______

Are you using, or is the baby receiving, any of the following? Please circle and explain amounts and frequency: breast pump, manual expression, juice, water, baby food, formula, pacifier, thumb sucking -- ______

______

When you give the baby solids or fluids, do you breastfeed before or after the supplements? ______How long do you intend to breastfeed your baby? ______

Medical History/Lifestyle Information

Height: _____feet _____inches; Weight: _____ pounds; Is your weight constant? _____ If no, please comment on any weight losses or gains: ______

Please describe your diet (e.g., vegetarian): ______

Recent illness: (date) ______(type) ______

Have you ever been diagnosed with any of the following? Indicate dates, if applicable:

vaginal infection (type) ______gynecological surgery (type) ______

sexually transmitted disease (type) ______cancer ______

uterine infection ______diabetes ______

tubal infection ______kidney disease ______

ovarian cysts ______thyroid/glandular disease (type) ______

endometriosis ______liver disorder (type) ______

cervical eversion, biopsy, etc. ______allergies (type) ______

Have you ever had any hormonal treatment, e.g., DES, Depo-Provera? ______

Did your mother take DES when she was pregnant with you? ______

Do you take vitamins? (type/amount) ______

Are you exposed to any chemicals or radiation-emitting devices? ______

List types/amounts/frequency of prescription drugs taken: ______

List types/amounts/frequency of non-prescription drugs taken: ______

List types/amounts/frequency of alcohol consumption and cigarette use: ______

Notes:

Birth Control History

Method / Dates Used / Why Discontinued/Problems
Pill
IUD
Condom
Diaphragm
Cervical Cap
Cervical Mucus
Sympto-Thermal
Basal Body Temp.
Spermicides
Withdrawal
Calendar Rhythm
Abstinence
None

Notes:


Infertility Test/Therapy History

Please indicate dates and results, if applicable.

BBT ______

LH Dipstick ______

Blood Tests ______

Postcoital/Huhner Test ______

Endometrial Biopsy ______

Transvaginal Ultrasound ______

Rubin’s Inflation ______

HSG (Hysterosalpingogram) ______

Hysteroscopy ______

Laparoscopy ______

Surgeries (type) ______

Ovulation Induction (type) ______

Artificial Insemination (type) ______

In Vitro Fertilization ______

Gamete Intrafallopian Transfer (GIFT) ______

Zygote Intrafallopian Transfer (ZIFT) ______

Other ______

How long have you been trying to achieve pregnancy? ______

Please list doctors you have seen regarding infertility:

Name Specialty

______

______

______

Notes:


Previous Breastfeeding Experience

For the last baby you breastfed:

How many times a day did you breastfeed? _____ Did you breastfeed day and night? ______

How old was your baby when you started giving solids or fluids? ______

Did you wean gradually or abruptly? ______

What did you give? ______

How much? ______

When you gave the baby solids or fluids, did you breastfeed before or after the supplements? ___

______

Did the baby use a pacifier? _____ How old was your child when bleeding returned? ______

Did you ever become pregnant before bleeding returned? ______

If yes, how old was the baby when you conceived? ______

How old was your child when you completely stopped breastfeeding? ______

Did you ever become pregnant while breastfeeding? ______

If yes, how old was the breastfed baby when you conceived? ______

Notes:

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