Abortion Intake Form

chart number
//
EXAMPLE : 23 / 6 / 2018
number of births
number of abortions
number of miscarriages
Did you take medications ?
kinds of medications
medical illness ?
medical illness
allergies to a medication ?
allergies
surgery
smoke ?
# of cigarettes a day
recreational drugs ?
recreational drugs or herbal medicines I use
blood clots, strokes ?
pain of period cramps #
birth control preference for future

Counselling Questionnaire:

- select an option -
- select an option -
- select an option -
0 - 10, degree of anxiousness
0 - 10, degree of depression
do you want an e-mail ?
Eg. yourname@gmail.com, @Yahoo.com , @telus.net / etc etc ...