Birth Control Consultation Form
What a birth control consultation form asks, with sample questions on past methods, periods, and health history.
A birth control consultation form records a patient's past and current birth control, preferences, periods, health history, and medicines before a contraception visit. The questions on this page come from contraception intake forms from the New York State and New Jersey health departments.
Birth control consultation form, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a birth control consultation form in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample birth control consultation form questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- Do you have a primary care provider?Background
- When was your last reproductive health visit?Background
- Have you ever used hormonal birth control?Method history
- Have you had a bad reaction to birth control?Method history
- Which method, if any, do you use now?Method choice
- Is there a method you would like to use?Method choice
- What was the first day of your last period?Periods
- Are you getting your period regularly?Periods
- Do you have diabetes?Health history
- Have you had weight loss surgery?Health history
- Do you take any medicines, herbs, or supplements?Medicines
- Are you allergic to any medicines?Medicines
These are examples to read, not a form to fill in.
Birth control consultation form: FAQ
What does a birth control consultation form ask?
The sample questions on this page are based on contraception intake forms from the New York State and New Jersey health departments. This page groups them into six areas: background, method history, method choice, periods, health history, and medicines.
Who fills in the form, and when?
The patient, before the contraception visit. Both state forms are completed by the patient and then reviewed by a pharmacist.
Does it ask which method the patient prefers?
Yes. The New York form asks whether the patient has a preferred method, with options such as the pill, patch, ring, injection, IUD, or implant.
Does a birth control consultation form ask about past reactions?
Yes. The New Jersey form asks whether the patient has had a bad experience with birth control, such as nausea, hair loss, weight gain, or headache.
Is there a birth control consultation form template?
The sample questions on this page show a typical set.
What happens after the form is completed?
Both state forms end with a section for the pharmacist after the patient's answers. AI Doctor only collects the answers and does not recommend a method.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
