Is there a sample questionnaire or checklist for family planning counseling for a reproductive‑age client?

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Family Planning Counseling Checklist

Yes, the CDC and U.S. Office of Population Affairs provide a structured framework for family planning counseling that includes specific assessment questions and clinical pathways for reproductive-age clients. 1

Core Assessment Questions (Reproductive Life Plan)

The foundation of family planning counseling centers on three essential questions that should be asked of every reproductive-age client: 1

  • "Do you have any children now?"
  • "Do you want to have (more) children?"
  • "How many (more) children would you like to have and when?"

These questions establish the client's reproductive intentions and guide all subsequent counseling and service provision. 1

Initial Visit Assessment Checklist

Primary Screening Questions

When a client presents for any reason, providers should systematically assess: 1

  • What is the client's reason for the visit? Understanding their primary concern ensures you address their immediate needs.
  • Does the client have another source of primary health care? This determines the scope of preventive services you should offer.
  • What is the client's reproductive life plan? Never assume based on age, sexual orientation, or disability status—always ask directly. 1

Sexual Health Assessment (Five P's Framework)

For clients seeking contraception or pregnancy-related services, conduct a structured sexual health assessment covering: 1

  • Practices: Types of sexual activity (vaginal, anal, oral)
  • Pregnancy prevention: Current contraceptive use, difficulties with current method, use at last intercourse, preferred method
  • Partners: Number, gender, concurrency of partners
  • Protection from STDs: Condom use patterns, situations affecting use
  • Past STD history: Personal history and partner history of STDs

Contraceptive Counseling Checklist

Method Education Requirements

When counseling about contraception, ensure clients understand: 1

  • Method effectiveness: Present typical-use failure rates using a tiered approach (most effective methods first—IUDs and implants before less effective options)
  • Correct use: Mode of administration and proper usage instructions
  • Side effects: Common and serious adverse effects
  • Return to fertility: Timeline after discontinuation
  • STD protection: Whether the method provides any protection (only condoms do)

Critical point: Even if a method is not available on-site, you must still discuss it and provide referral options. Omitting methods solely due to unavailability is inappropriate. 1

Medical Eligibility Screening

Before prescribing contraception, assess: 1

  • Current medications (potential drug interactions)
  • Medical conditions that may contraindicate specific methods
  • Smoking status and age (relevant for combined hormonal methods)
  • Blood pressure (for hormonal methods)
  • Pregnancy status (always rule out first)

Pregnancy Testing and Counseling Checklist

For Positive Pregnancy Tests

When pregnancy is confirmed, provide: 1

  • Gestational age estimation (assess last menstrual period; perform pelvic exam if uncertain)
  • Options counseling covering all three options: continuing pregnancy, adoption, or abortion
  • Initial prenatal guidance: Prenatal vitamins with folic acid, avoid smoking/alcohol/drugs, avoid high-mercury fish
  • Medication review: Identify potentially teratogenic medications
  • Referral coordination: Make appointments or provide directory of prenatal care providers
  • Social support assessment: Screen for need for counseling or supportive services

For Negative Pregnancy Tests

When pregnancy is ruled out: 1

  • Explore why the client thought she was pregnant (missed contraception, method failure, irregular cycles)
  • Assess difficulties with current contraceptive method
  • Offer contraceptive services immediately (clients may not return for a separate visit)
  • Discuss reproductive life planning

Preconception Counseling Checklist

For clients who want to become pregnant, assess: 1

Fertility Optimization Counseling

  • Duration trying to conceive: Standard infertility definition is 12 months of unprotected intercourse (6 months if age >35 years, history of irregular cycles, known tubal/uterine disease, or subfertile partner) 1
  • Timing of intercourse: Educate about the 6-day fertile window ending on ovulation day; recommend intercourse every 1-2 days after menses ends
  • Ovulation tracking methods: Discuss cervical mucus changes, ovulation predictor kits, apps, cycle beads
  • Lifestyle factors affecting fertility: 1
    • Weight (very thin or obese reduces fertility)
    • Caffeine (>5 cups/day reduces fertility)
    • Smoking, alcohol, recreational drugs (all reduce fertility)
    • Commercial vaginal lubricants (most reduce fertility)

Preconception Health Optimization

  • Folic acid supplementation: 400 mcg daily to reduce neural tube defects 1
  • Body mass index assessment: Counsel on achieving healthy weight before conception 1
  • Chronic disease control: Optimize diabetes (A1C as close to normal as possible), hypertension, seizure disorders, thyroid disease 1
  • Medication review: Identify and switch teratogenic medications to safer alternatives 1
  • Immunization update: Hepatitis B, influenza, MMR, Tdap, varicella as needed 1
  • STD screening: Test for chlamydia, gonorrhea, syphilis, HIV as indicated 1

Adolescent-Specific Considerations

When counseling adolescents, ensure services are "youth-friendly": 1

  • Encourage parental involvement while respecting confidentiality
  • Provide education materials for parents about discussing sex and values
  • Screen for repeat pregnancy risk (20% of adolescent births are repeat births)
  • Refer to home visiting programs for pregnant/parenting teens

Common Pitfalls to Avoid

  • Never assume reproductive intentions based on age, marital status, sexual orientation, or disability. 1
  • Do not withhold information about methods unavailable at your site—discuss all options and provide referrals. 1
  • Avoid delaying contraceptive services for additional testing unless medically necessary; preventive services should not become barriers. 1
  • Do not perform unnecessary pelvic exams for contraception initiation (not required for pills, patches, rings, injections). 2
  • Never omit long-acting reversible contraception (IUDs and implants) from counseling—these are safe and highly effective for nulliparous women and adolescents. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Initial Workup for Irregular Menses (Oligomenorrhea or Amenorrhea)

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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