Abortion Intake Form Please enable JavaScript in your browser to complete this form.Chart #chart number1. What was the first day of your last normal menstrual period ? — Please enter Day / Month /YearDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EXAMPLE : 23 / 6 / 20182. What form of birth control were you using when you got pregnant? (including condoms, counting safe days, withdrawal, etc) 3. Have you ever been pregnant before ? YesNo4. How many Births ? :number of births5. How many Abortions ? : number of abortions6. How many Miscarriages ? : number of miscarriages7. Any complications or problems with previous pregnancies ? Yes, there were complicationsNoWhat kind of complications ?8. Do you take any regular medications ?YesNoDid you take medications ?If Yes, what kind of medications ?kinds of medications9. Do you have any medical illnesses like asthma, diabetes, liver or kidney disease, migraines ?YesNomedical illness ?If Yes, what kind ?medical illness10. Are you allergic to any medications ?YesNoallergies to a medication ?If Yes, what kind of allergies ?allergies11. Have you ever had surgery before ? YesNoIf Yes, what kind of surgery ? surgery12. Do you smoke ?YesNosmoke ?If Yes, how many cigarettes a day ?# of cigarettes a day13. Do you use recreational drugs (marijuana, ecstasy, cocaine, etc.) or herbal medicines ? YesNorecreational drugs ?Which ones and how much ?recreational drugs or herbal medicines I use14. Has any of your family members under the age of 50 had blood clots or strokes ?YesNoblood clots, strokes ?15. How would you rate your worst period cramps on a scale of 0 to 10, where 0 is no pain and 10 is pain as bad as it can be ? pain of period cramps #16. What kind of birth control methods have you used in the past ? CondomsDiaphragmBirth control pillsRhythm (counting safe days)IUDDepo ProveraWithdrawl (pulling out)Others17. What kind of birth control method would you like to use in the future ?birth control preference for futureCounselling Questionnaire:1. I have been able to talk about my decision to have an abortion with:My partner/husband/boyfriendFamilyFriendsDoctor/professional counsellorNo one knows- select an option -2. My partner/husband/boyfriend:is very supportivebelieves it is my choiceis not supportivedoes not know about the pregnancy or abortionI do not have a partner- select an option -3. I feel that:I am sure about my decision to have an abortionI feel somewhat unsure but believe that having an abortion is the best choiceI have serious conflicts about my decision to have an abortion- select an option -4. My main concerns are:My conflicting feelings about having an abortionMy relationship with my partnerPossible effects on future pregnanciesHow I will feel emotionally afterwardsMy religious beliefspain5. Whose decision is it for you to have this abortion ?6. How anxious do you feel on a scale of 0 to 10, where 0 is not anxious at all and 10 is the most anxious you have ever been ?0 - 10, degree of anxiousness7. How depressed do you feel on a scale of 0 to 10, where 0 is not depressed at all and 10 is the most depressed you have ever been ?0 - 10, degree of depression8. Is there anything else the counsellor should know about you to give you the support you need ?9. Do you want a counsellor to email you after your abortion to see how you are doing ?YesNodo you want an e-mail ?If Yes, what is your e-mail address ?Eg. yourname@gmail.com, @Yahoo.com , @telus.net / etc etc ...PhoneSubmit
