Low dose oral contraceptive (OC) ： Check list for questioning

Low dose oral contraceptive (OC) ： Check list for questioning

ふりがな　　 Taking the pill now?⇒ Yes No
　　Name 　　Hospital card No.

●If you are visitor please write down below
〒 Address
Phon Cell phon 　　　　Birth date / /
May i call your cellphon if i need it? Yes No 　　　　　　　　　　　　　　　　　　　　　　　　age

1.購入希望するピルシートの枚数は？	Sheet
2.If you are a smoker,please enter the number of cigarettes you smoke daily.	cigarettes per day
3.Are you taking any drugs now?	Yes No
4.Are you receiving treatment by a physician now?	Yes No
5Have you experienced hypersensitivity when you took other oral contraceptives or hormones before?	Yes No
6.Have you said to have brease, cervical, cancer or any other malignant tumor?	Yes No
7.Do you have genital bleeding?	Yes No
8.Will you undergo a big operation, or did you undergo an operation recently?	Yes No
9.Are you pregnant now, or considering to be pregnant?	Yes No
10.Are you lactating now?	Yes No
11.Were you said to have high blood pressure?	Yes No
12.Were you said to have hyperlipemia (abnormal lipid metabolism)?	Yes No
13.Were you said to have bronchial asthma?	Yes No
14.Have you been said to have varicose vein?	Yes No
15.Were you said to have any of the tollowing? thrombophlebitis 　　　 pulmonary embolism　 cerebrovascular disorder coronary arterial disorder 　 cardiac diseases renal disorders dia betes	Yes No