Distance Questionnaire (abortion intake)

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Willow Clinic

Willow Reproductive Health Centre

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Abortion Intake Form

Chart #

chart number

Pregnancy Dating

1. When was the first day of your last period?

2. What type of contraception were you using when you got pregnant?

Define what other type of contraception were you using when you got pregnant?

Pregnancy Symptoms

3. Have you had any bleeding during this pregnancy

Yes
No

Obstetric History

4. Have you ever been pregnant ?

Yes
No

5.1 How many Births (Vaginal)?

Number of births

5.2 How many Births (C-section)?

Number of births

5.3 How many Miscarriages ? :

Number of miscarriages

5.4 How many Medication Abortions?

Number of Medication Abortions

5.5 How many Surgical/Aspiration Abortions ?

Number of Surgical/Aspiration Abortions

5.6 How many Ectopic pregnancies ?

Number of Ectopic pregnancies

Medical History

6. Do you have an allergy to latex?

Yes
No

7. Are you allergic to any medications ?

Yes
No

If yes, please list (comma separated):

8. Do you have any current or past medical illnesses such as asthma, anemia (or low iron), or migraine headaches?

Yes
No

If yes, please list (comma separated):

9. Do you take any medications, supplements, or vitamins?

Yes
No

If yes, please list (comma separated):

10. Have you ever had surgery?

Yes
No

If yes, please list year and type of surgery (comma separated):

11. When was the last time you had a cervical screen (PAP or HPV test)?

Never
Select Date

Enter Date (mm/dd/yyyy)

Social History

12. Do you smoke cigarettes or vape nicotine?

Yes
No

smoke ?

If you smoke cigarettes, how many per day?

# of cigarettes a day

Phone

Phone: (604) 709-5611 Fax: (604) 873-8304 Location: Suite 1013 – 750 West Broadway Vancouver, BC V5Z 1H9