1.

Are you pregnant or do you think you may be?

2.

Have you recently had a pregnancy test?

If yes, test date?

Doctor:

3.

Do you have menstrual cycles?

Last menstrual period start date:

4.

Do you practice birth control?

Please indicate the method of birth control:

5.

Have you been sexually active since your last menstrual period?

1.	Are you pregnant or do you think you may be? Yes No
2.	Have you recently had a pregnancy test? Yes No If yes, test date? Negative Positive Doctor:
3.	Do you have menstrual cycles? Yes No Last menstrual period start date:
4.	Do you practice birth control? Yes No Please indicate the method of birth control:
5.	Have you been sexually active since your last menstrual period? Yes No