You are on page 1of 2

ORAL CONTRACEPTIVES EFFECT ON YOUR HEALTH

A QUESTIONNAIRE FOR BC 25-B, SUMMER, 2013


SILLIMAN UNIVERSITY
Name (optional): __________________________________
Age: _________
Put a check mark on the blanks that correspond
your answers, or provide the necessary information.
1. Do you take oral contraceptives or birth control
pills?
____ Yes
____ No
If yes, please continue answering numbers 210.
If no, please proceed to number 11-13.
2.

What classification of oral contraceptives do


you take?
_____ Combined Oral Contraceptives
_____ Progestin Only Contraceptive
_____ Both
_____ You dont know

3. Do you know that there are risks of taking the


pill?
______ Yes
______ No
If no, please continue answering number 4.
If yes, what do you think are these risks?
(Please check as applicable)
_____Increased risk of Cervical and Breast
Cancer
_____ Adverse effects on the physical aspect of
the
body.
____ Adverse effects on the emotional aspect of
the
body
____ Others, please specify,
___________________________________
4. How long have you been taking oral
contraceptives?
_____ Less than one year
_____ 1-2 years
_____ 3-5 years

_____ More than five years


5. What are the reasons why you take the pill?
(Please check as applicable)
______ Doctors prescription
______ Effective contraceptive
______ Normal menstruation
______ Healthy skin
______ Others, please specify,
_________________________
6. What do you think are the benefits you obtained
from taking the pill? (Please check as applicable)
_______ Effective contraceptive
_______ Normal menstruation
_______ Healthy skin
_______ Others, please specify,
________________________
7. After taking the pill, did you experience any
negative physical effects on your body?
______ Yes
_____ None
If none, continue answering number 8
If yes, what are these negative effects?
(Please check as applicable)
_______ Dizziness
_______ Nausea
_______ Hypertension/ High Blood Pressure
_______ Gall bladder stones
_______ Difficulty in urinating
_______ Others, please specify,
________________________
.
8. After taking the pill, are there any negative
effects on your behavior and personality?
______ Yes
______ None
If no, continue answering number 9
If yes, what are these?
(Please check as applicable)
______ Mood swings

______ Loss of libido/ loss of sexual desires


______ High level of anxiety
______ Others, please specify,
_________________________
9. Do you believe that taking these pills would
increase probability of having cancer?
_______ Yes
______ No
10. If Proven that the taking the pill would increase
the risk of having cancer, will you stop taking
the pill?
_______ Yes
______No

Only those who answered No in number 1 may


answer numbers 11-13
11. What are your reasons for not taking the pill?
(Please check as applicable)
____ You are using other types of contraceptives
____ You know the risk of taking these pills
____ You think these pills are not effective
____ You do not need to use contraceptive
____ Others, please specify,
___________________________
12. Do you think that taking these pills would
increase probability of having cancer?
____ Yes
___ No
13. Do you have any plan taking these pills on the
future?
____ Yes
___ No

If you have any suggestions/ comments/ additional


insights/ questions about the topic, please write
them on the space below.

Thank you for your participation.