Please complete this feed back form to help us assess community family planning needs so that we may serve you better. Thank you!

Question Title

* 1. What is your age?

Question Title

* 2. What is your assigned sex at birth?

Question Title

* 3. What is your ethnicity? (Please select all that apply)

Question Title

* 4. What is the highest level of education you completed? (Check 1)

Please answer the following questions to the best of your knowledge.

Question Title

* 5. Have you ever used LCHC Family Planning Services? (STD Testing, Pregnancy Test, Birth Control Options)

Question Title

* 6. Are you aware that we offer birth control pills and other birth control methods for low or no cost?

Question Title

* 7. Are you aware that we offer FREE condoms?

Question Title

* 8. Are you aware that we offer FREE STD (Sexually Transmitted Disease) screening?

Question Title

* 9. What type of birth control methods have you heard of? Also note which you are interested in learning more about. (Check all that apply)

  Heard of Method Want More Information
Oral contraceptive (pills)
Depo Shot
Patch (Ortho Evra)
Vaginal Ring (NuvaRing)
IUD (Mirena/Skyla/Paraguard)
Implant (Implanon/Nexplanon)
Male Condom
Female Condom
Vasectomy "snip-snip"
Tubal Ligation "tubes tied"
Hysterectomy (removal of womb)
Abstinence (no sex)

Question Title

* 10. What are some barriers that prevent you from seeking care?  Select all that apply.

Question Title

* 11. Are you on birth control right now?

Question Title

* 12. If you answered NO to question 11, what is the reason? Check any of the following:

Question Title

* 13. If you use condoms as a birth control method, how often do you use condoms?

Question Title

* 14. Have you received any family planning education (sex education)?

Question Title

* 15. If you answered YES to question 14, from where?

Question Title

* 16. Do you find family planning services easy to access?

Question Title

* 17. What family planning services would you like more information on?  Select all that apply.

Question Title

* 18. How do you prefer to learn about family planning? Select all that apply.

Question Title

* 19. Would you prefer an in person or virtual/telehealth appointment?

Question Title

* 20. If you would like more information on family planning please call our office at 808-565-6919 to schedule an in-person or virtual appointment or visit the website: https://www.cdc.gov/reproductivehealth/contraception/index.htm

You may also leave a name, phone number or email address and we can contact you directly. Mahalo!

T