Birth Control Method Evaluation Form
Name
Date
Birth Control Method Used
Pill
Patch
IUD
Implant
Condom
Injection
Vaginal Ring
Other
How long have you used this method?
How easy was this method to use?
Very Easy
Easy
Neutral
Difficult
Very Difficult
Have you experienced any side effects?
How effective was the method for you?
Very Effective
Effective
Somewhat Effective
Not Effective
Overall satisfaction with this method
Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
Additional Comments