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Birth Control Illness Dose Note Sheet
A plain note sheet for birth control, illness, and dose questions: record what happened and ask a pharmacist or clinician.
Illness can make a pill question feel urgent.
This sheet slows the question down.
It helps you record facts for a pharmacist or clinician.
It does not tell you what dose to take. It does not tell you what to do after a late or missed pill. It does not tell you if you need another method or emergency contraception. It does not read pregnancy risk.
Pill and illness card
Fill this in before you call.
Question Your note Birth control name Pill type, if known combination / progestin only / not sure Package directions found? yes / no / not sure Usual pill time Dose question in your words Illness started Main symptom vomiting / diarrhea / fever / nausea / other New medicine New supplement Who you plan to ask pharmacist / clinician / urgent care
Write the question. Do not answer it yourself.
Daily illness notes
Use one row per day.
Date Pill note Vomiting Diarrhea Other medicine Question taken / late / missed / not sure none / yes / not sure none / yes / not sure
Keep the words simple.
Do not use this sheet as a dosing plan.
Medicine list
List everything that may matter.
Item Name When started Label or dose note Who prescribed or sold it Birth control Prescription Over the counter medicine Vitamin Herb or supplement
Include St. John's wort if it appears on a label.
Bring bottles, photos, or labels if you can.
What to ask
What facts do you need from my pill package? Does my pill type matter for this question? Does the illness pattern matter? Could another medicine or supplement matter? Should I call a prescriber today? What symptoms mean I should seek care? What should I avoid changing on my own?
Portal message draft
"I use birth control pills. I was sick and have a dose question. I do not want to guess. My pill name is . My main symptoms were . I also took . What facts do you need from me?"
Keep the message short.
Do not include private details that are not needed.
One page summary
Use this if you get a visit.
Summary item Your note Pill name Pill type, if known Illness dates Main symptoms Pill notes Medicine or supplement changes Package directions question Main worry Help I need
Ask your care team what the facts mean.
Privacy note
Dose notes can include birth control names, sex worries, pregnancy worries, missed pills, stomach symptoms, pharmacy names, and clinic messages.
Keep only what helps you ask your question.
Floriva can keep short notes on your device. It does not promise privacy. It does not replace package directions, a pharmacist, a clinician, or urgent care.
For more help, use the birth control vomiting diarrhea question list, birth control medicine interaction checklist, and birth control side effect tracker.