| 1. Are you sexually active? |
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| 2. If a birth control method, such as a diaphragm, cervical cap or condom interrupts lovemaking, are you less likely to use it? |
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| 3. Do you think you would remember to take a pill at about the same time every day, 365 days a year? |
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| 4. Are you ok with going to your health care provider's office every three months to get a shot? |
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| 5. In general, does learning that a birth control contains hormones make you less likely to use it? |
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| 6. Do you smoke? |
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| 7. Are you or your partner allergic to latex? |
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| 8. Do you plan to get pregnant within the next five years? |
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| 9. Do you plan to get pregnant within the next 12 months? |
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| 10. Do you want the choice of getting pregnant in the future? |
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