Medical Abortion Intake – Willow Clinic

Willow Clinic
Willow Reproductive Health Centre

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Medical Abortion Intake Form

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chart number
3. Have you had any bleeding during this pregnancy
4. Have you ever been pregnant ?
Number of births
Number of births
Number of miscarriages
Number of Medication Abortions
Number of Surgical/Aspiration Abortions
Number of Ectopic pregnancies
6. Do you have an allergy to latex?
7. Are you allergic to any medications ?
8. Do you have any current or past medical illnesses such as asthma, anemia (or low iron), or migraine headaches?
9. Do you take any medications, supplements, or vitamins?
10. Have you ever had surgery?
11. When was the last time you had a cervical screen (PAP or HPV test)?
12. Do you smoke cigarettes or vape nicotine?
smoke ?
# of cigarettes a day

About Us

Willow Reproductive Health Centre is committed to delivering compassionate, inclusive, and high-quality reproductive health care, ensuring every patient feels respected, safe, and supported.

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