Standards for Female and Male Sterilization Services - STATE ...
Standards for Female and Male Sterilization Services - STATE ...
Standards for Female and Male Sterilization Services - STATE ...
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56<strong>St<strong>and</strong>ards</strong> <strong>for</strong> female <strong>and</strong> male <strong>Sterilization</strong> servicesB. Obstetrics history (<strong>for</strong> female acceptors)No. of spontaneous abortions .................................................................................................No. of induced abortions .................................................................................................Currently lactatingYes...........................................................................................No...........................................................................................AmenorrhoeicYes...........................................................................................No...........................................................................................Whether pregnantYes...........................................................................................No...........................................................................................If yes (no. of weeks of pregnancy)...................................C. Contraceptive historyHave you or your spouse ever used anycontraception?Are you or your spouse currently using anycontraception, or have you or your spouse used anycontraception during the last 6 months?Yes...........................................................................................No...........................................................................................None.......................................................................................IUCD......................................................................................Condoms................................................................................Oral pills.................................................................................Any other (specify)...............................................................D. Medical historyRecent medical illnessPrevious surgeryAllergies to medicationBleeding disorderAnaemiaDiabetesJaundice or liver disorderRTI/STI/PIDConvulsive disorderTuberculosisMalariaAsthmaHeart diseaseYes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................