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Subdermal Birth Control Implant Questionnaire

This document appears to be an interview form used to gather information about a person's knowledge and experience using subdermal birth control implants. The form collects demographic information and asks questions about the person's reasons for choosing the implant, their experience using it including any side effects, their thoughts on whether it was the right choice, and future plans regarding the implant. The questions are open-ended to allow the person being interviewed to provide detailed responses. All information collected is to be kept confidential.

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Sarah Jane
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36 views

Subdermal Birth Control Implant Questionnaire

This document appears to be an interview form used to gather information about a person's knowledge and experience using subdermal birth control implants. The form collects demographic information and asks questions about the person's reasons for choosing the implant, their experience using it including any side effects, their thoughts on whether it was the right choice, and future plans regarding the implant. The questions are open-ended to allow the person being interviewed to provide detailed responses. All information collected is to be kept confidential.

Uploaded by

Sarah Jane
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SUBDERMAL BIRTH CONTROL IMPLANT INTERVIEW FORM

In connection with the research that we are conducting about knowledge and attitude on subdermal implants, we
would like to questions from you.. Information gathered from this activity can be used to improve current family planning
program. All information you provide will be considered CONFIDENTIAL.

CODE: DATE: RESPONDENT NO:


GENERAL PROFILE
Name/Nickname: Age: Address:
Educational Attainment: Civil Status: Occupation:
Estimated Gross Monthly Family Income (including spouse’s income) (Php): _________________
Obstetrics history: Gravida ___ Para ___ How many children do you currently have?
HISTORY OF IMPLANON USE
Reason for Family Planning:  Spacing  Limiting
When did you get your implant?  First insertion __________ Second insertion________
From whom/where have you heard about  Medical Professional  TV/Radio Others_________
Implanon? (Check as many as appropriate)  Partner  Newspaper/Magazine /Pamphlet
Where did you avail the method?  ZCMC  Clinic  NGOs  Private Hospital  Health Centers  Others___

Who inserted the implant?  Doctor  Midwife  Nurse  Others_________


Other FP method used in the past?
QUESTIONS:

1. Tell me anything you know about the implant. _________________________________________________


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2. What made you decide to use the implant? _________________________________________________
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3. Could you tell me about your experience with using the implant? Any side effects or what you feel?
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4. Do you think you made the right choice of choosing the implant? What made you said so?
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5. What are your future plans about the implant? Will you have it reinserted after expiry? For what reason?
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PARTICIPANT’S SIGNATURE: INTERVIEWED BY:

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