1. What type of birth control (Condoms, pills, pulled out) did you use, if any?______________________________________________________
2. Were there any problems with your protection (condom breaking, missing pills)?
3. Are you trying to get pregnant, or avoiding it?
4. How many days are between the first day of one period and the first day of your next?
5. Any changes which could change your cycle (major change in diet, exercise, new medication, new stress?)
6. What was the month/day your last period started?
7. What date(s) did you have sex?
8. Where was ejaculation(in vagina, in condom, pulled-out)?
9. Is there anything else that makes you think you're pregnant?
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