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Guide Book for Health-Care Providers

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Client Record Proforma

Client Record Proforma
S. No. : ____________

1.	Name (Optional)	_____________________
2.	Age	_____________________
3.	Married / Unmarried	_____________________
4.	Date of last menstrual period	_____________________
5	Length and duration of menstrual cycle	_____________________
6.	Number of unprotected acts of intercourse in the current cycle	_____________________
7.	Time and date of each act of unprotected date time duration intercourse with relation to administration of EC	_____________________
8.	Contraception used in the current cycle	_____________________
9.	Is she at high risk for STDs	_____________________
10.	Obstetric history/MTP/Abortion if any	_____________________
11.	Medical history	_____________________
12.	Date and time of ECP use 1st dose	_____________________
13.	Reasons for ECP use : Condom failure Forgotten OCP No contraceptive used Sexual assault Others specify

FOLLOW-UP

1.	Date of visit	_____________________
2.	History of further sexual acts after ECP	_____________________
3.	Date of menses	_____________________
4.	Duration and amount of bleeding	_____________________
5.	Any side effects	_____________________
6.	Regular contraceptive chosen	_____________________
7.	If no period, pregnancy test	_____________________
8.	Pregnancy outcome	_____________________

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