Medical abortion questionnaire

Please complete this form after you have booked a medical abortion appointment with us. You should fill in all of the form, and please note that any question marked with an * must be completed in order to be able to submit the form to us. Also, please enter your full name:











YesNo





Yes, there were complicationsNo



YesNo



YesNo



YesNo



YesNo



YesNo



YesNo



YesNo



IUDsCondomsBirth control pillsWithdrawalEvra patchNuvaringDepo shot


210 – 2525 Commercial Drive, Vancouver, BC
Phone hours: 9:30 am – 4:00 pm
Monday to Friday

Appointments: 604-322-6692
business inquiries only: 604-322-6576
Fax: 604-322-6632

Everywoman’s sits on the traditional, ancestral, and un-ceded territory of the Coast Salish peoples– xʷməθkʷəy̓əm (Musqueam),  Səl̓ílwətaʔ/Selilwitulh (Tsleil-Waututh), and Sḵwx̱wú7mesh (Squamish).