Nevada Administrative Code › Chapter 639 - Pharmacists and Pharmacy › Section 639.Sec. 5 - NEW

Current through June 11, 2024
The risk assessment questionnaire described in paragraph (a) of
			 subsection 2 of section 2.5 of Senate Bill No. 190, chapter 504, Statutes of
			 Nevada 2021, at page 3268 (NRS 639.28077) , must be in substantially the
			 following form:
HORMONAL CONTRACEPTIVE RISK ASSESSMENT QUESTIONNAIRE FOR PATIENT
			 COMPLETION
Note to patient: Complete this questionnaire and bring to your
			 pharmacy for selfadministered hormonal contraceptives. You should call your
			 pharmacy first to make certain the pharmacy is able to provide this service.
			 You may also obtain the questionnaire from participating pharmacies.
Patient Name:
			 ..........................................................................
			 Date:.................................
Date of Birth: ..............................
			 Age:.................. Weight:................. Height:
			 ...................
Email address: ..................................... Telephone
			 Number: .................................................
What was the date of your last women's health clinical visit?
			 ___/___/___
Any allergies to medications? Yes [] No []
If yes, list them here:
			 ...............................................................................................................
Do you have a preferred method of birth control that you would
			 like to use?
A daily pill [] A weekly patch [] A monthly vaginal ring []
			 Injectable (every 3 months) []
1
Do you think you could be pregnant now?
Yes []
No []
2
What was the starting date of your last menstrual
						  period?
___/___/___
3
Have you ever taken birth control pills or used a birth
						  control patch, ring, shot or injection?
Yes []
No []
- If yes, have you previously had contraceptives
						  dispensed to you by a pharmacist?
Yes []
No []
4
Have you ever experienced a bad reaction to using
						  hormonal birth control?
Yes []
No []
- If yes, what kind of reaction occurred?
5
Are you currently using birth control pills or a birth
						  control patch, ring, shot or injection?
Yes []
No []
6
Have you ever been told by a medical professional not
						  to take hormones?
Yes []
No []
7
Do you smoke cigarettes?
Yes []
No []
8
Have you had a recent change in vaginal bleeding that
						  worries you?
Yes []
No []
9
Have you given birth within the past 21
						  days?
Yes []
No []
- If yes, what was the date of the birth?
						  ___/___/___
10
Are you currently breastfeeding?
Yes []
No []
11
Do you have diabetes?
Yes []
No []
12
Do you get migraine headaches?
Yes []
No []
- If yes, have you ever had headaches that start with
						  warning signs or symptoms, such as flashes of light, blind spots or tingling in
						  your hand or face that goes completely away before the headache
						  starts?
Yes []
No []
13
Do you have high blood pressure, hypertension or high
						  cholesterol? (Please indicate yes even if your hypertension is controlled by
						  medication.)
Yes []
No []
14
Have you ever had a heart attack or stroke or been told
						  by a medical professional that you have heart disease?
Yes []
No []
15
Have you ever had a blood clot?
Yes []
No []
16
Have you ever been told by a medical professional that
						  you are at a high risk of developing a blood clot?
Yes []
No []
17
Have you ever had bariatric surgery or stomach
						  reduction surgery?
Yes []
No []
18
Have you had recent major surgery or are you planning
						  to have surgery in the next 4 weeks?
Yes []
No []
19
Do you plan to have restricted mobility for a long
						  period of time? (e.g. a long airplane trip, etc.)
Yes []
No []
20
Do you have or have you ever had breast
						  cancer?
Yes []
No []
21
Do you have or have you ever had hepatitis, liver
						  cancer or gall bladder disease, or do you have jaundice (yellow skin or
						  eyes)?
Yes []
No []
22
Do you have lupus, rheumatoid arthritis or any blood
						  disorders?
Yes []
No []
23
Do you take medication for seizures, tuberculosis (TB),
						  fungal infections or human immunodeficiency virus (HIV)?
Yes []
No []
- If yes, list the medications here:
24
Do you have any other medical problems or take regular
						  medication(s)?
Yes []
No []
- If yes, list problems or medications
						  here:
25
Do you take any herbal or vitamin
						  supplements?
Yes []
No []
- If yes, list supplements here:
Patient Signature:
			 .................................................................
			 Date:.......................................
Reviewing Pharmacist Signature:
			 .......................................
			 Date:.......................................
Added
			 to NAC by Bd. of Pharmacy by
			 R036-21A,
			 eff. 2/28/2022
NRS
			 639.070 and section 2.5 of Senate Bill No.
			 190, chapter 504, Statutes of Nevada 2021, at page 3268 (NRS 639.28077)
			 .