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FAMIL Y PLANNING CLINIC - Pregnancy Testing Form Date ------------------- MENSTRUAL HISTORY First day of last menstrual period Was this a normal period? Yes No Have you had: (Check all that apply) Nausea? Sleepy/Tiredness? Was it Light Medium Increased Urination? Breast Tenderness? CONTRACEPTIVE HISTORY Are you currently using a birth control method? Yes No If you are currently using a birth control method, what...
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