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Date
Clinic
Provider

Patient Name
Date of Birth
Patient Number
Mother's Name
Father's Name

Level of Education	How did you learn about this family planning service?
Productive History	Last Pregnancy Result of Last Pregnancy: Specify Complication:
Last Menstrual Cycle Result of Last Menstrual Cycle:	Are you currently breastfeeding?
Do you want you want to have more children Medical History	Previous Method of Contraceptive Used

Blood Pressure: / Breasts: Other Observations:

Type Selected

Referral to Other Facility