League City Family Clinic

Are you a Texas resident? *

Do you have a personal history of breast, uterine, or cervical cancer? *

Yes

No

Unsure

Do you have a history of blood clots, DVTs, or Pulmonary Embolism? *

Yes

No

Unsure

Do you have history of stroke, heart attacks, coronary artery disease, or valvular heart disease? *

Yes

No

Unsure

Do you have any history of chronic liver disease? *

Yes

No

Unsure

Do you have uncontrolled blood pressure? *

Yes

No

Unsure

Do you have a history of porphyria? *

Yes

No

Unsure

Are you pregnant or breastfeeding? *

Yes

No

Unsure