Patient Follow-Up & Survey Patient Follow Up & Survey for FCHC patients Name* First Last This field is hidden when viewing the formToday's Date MM slash DD slash YYYY Date of Birth* Month Day Year Phone*May we leave a message?* Yes No Email Prefered Method of Contact:* Phone Email Follow-Up EvaluationDate of Procedure:* MM slash DD slash YYYY Tell us about your recovery:What are the results of your at-home pregnancy test?* Not Pregnant Pregnant How are you feeling now?*Do you have any concerns?*Tell us about your bleeding:Number of days of bleeding*Color of Bleeding* Red Pink Brown Mixture of All Are you still bleeding?* Yes Just spotting No Did you have clots?* Yes No How often did you have clots?*Size of clots*Additional Questions:Did you have any other vaginal discharge?* Yes No Was there odor?* Yes No Please describe further if needed:Do you still have nausea?* Yes No Do you still have breast tenderness?* Yes No Did you start any hormonal birth control?* Yes No When did you start hormonal birth control?* MM slash DD slash YYYY I would like a prescription for birth control I would like a prescription for birth control Name of PharmacyPharmacy Phone numberWhen was your last Well Woman Exam / Pap Smear test?Can we help you with any GYN services or concerns?* Yes No How can we help you?*Have you had sexual intercourse since your procedure?* Yes No Was protection used?* Yes No Would you like us to call you to answer any further questions you may have?* Yes No CAPTCHA
