Por favor, activa JavaScript en tu navegador para completar este formulario.Name *Last name *ID card *Age *Contact phone number *Email *Please verify that your email address is spelled correctly, as we will contact you through this address.Marital Status *Single womanMarriedDivorceeWidowOccupation *Sexual OrientationHeterosexualityHomosexualityBisexualityPansexualityAsexualityOtherNOTE: We understand, respect, and value privacy. The purpose of this question is purely medical. Knowing your sexual orientation is important to prioritize your eligibility for the intradermal device. Clinical InformationNumber of pregnancies you have had *None123More than 3Date of last menstrual period *Weight *Expressed in kilogramsHeight *Expressed in centimetersHave you suffered or are you currently suffering from any of the following STIs?SyphilisChlamydiaGenital herpesGonorrheaHIV/AIDSHPVTrichomoniasisDo you have a history of polycystic ovaries? *YeahNoDon't knowHave you been diagnosed with diabetes? *YeahNoDon't knowHave you been diagnosed with hyperinsulinism? *YeahNoDon't knowHave you been diagnosed with any thyroid disease ?YeahNoDon't knowWrite down which thyroid disease you suffer fromDo you have a history of thrombosis? *YeahNoDon't knowDo you have varicose veins in your legs? *YeahNoDon't knowSexual health Have you already started your sexual activity? *YeahNoAt what age did you begin your sexual activity? *Expressed in numbersNumber of sexual partners you have had *Expressed in numbersAre you currently undergoing any treatment for any illness ?YeahNoWrite the name of the medication or medications.Have you previously had an intradermal contraceptive device inserted ?YeahNoPlease select if you use any of the following contraceptive methodsPillscopper TSIU (intrauterine system)ImplantsBarrier methods (male and/or female condoms)I confirm that the information I have provided is correct and truthful .AcceptSend
