Test Form

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This is a survey sample!

Please fill this questionnaire to complete your order.

What was your sex assigned at birth?

Male

Female

How old are you?

We cannot prescribe birth control to you if you are under 18.

What was your latest blood pressure reading in the last 6 months? Generated Image

Low

Normal

High

Very High

Please select the following menstrual issues that apply to you.

We cannot prescribe this medicine to you if any of the following apply to you. Instead, we recommend going to the hospital.

Abnormal vaginal bleeding different from your usual period

Periods have become more frequent or heavier than your usual period

Abnormal bleeding between your periods

None of the above

Please select at least one option.

Are you allergic to any medicines? If yes, please list them below.

Thank you for filling the form!

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