Vasectomy Patient Log

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Vasectomy Patient Log: NSVI Kenya Domestic Team
Date: ________________ Location: __________________
# of
children with
Children w/
Present
All children
Total # of
how many
present
partner's
Age of
planned?
Recent method
Case
Last Name
First Name
Age
Children
partners?
partner
age
youngest child
(Y/N)
of birth control
1
2
3
4
5
6
7
8
9
10

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