Medical abortion questionnaire

Your full name, first and last*

Date of your FIRST appointment with us*

Appointment time*

Date of Birth*

Email Address*

What was the first day of your last menstrual period?*

What, if any, form of birth control were you using when you got pregnant? (including condoms, counting safe days, withdrawal, etc)*

Have you been pregnant before?*
YesNo

Number of births:

Number of abortions:

Number of miscarriages:

Any complications or problems with previous pregnancies?*
Yes, there were complicationsNo

If yes, what kind of complications?

Do you take any medications?*
YesNo

If yes, what medications do you take?

Do you have any medical illnesses like asthma, diabetes, liver or kidney disease, migraines?*
YesNo

If yes, what illnesses do you have?

Are you allergic to any medications?*
YesNo

If yes, what kind of allergies?

Have you ever had surgery before?*
YesNo

If yes, what kind of surgery?

Do you smoke cigarettes?*
YesNo

If yes, how many cigarettes a day?

Do you use recreational drugs (marijuana, ecstasy, cocaine, etc.) or herbal medicines?*
YesNo

If yes, which ones and how much?

Has any of your family members under the age of 50 had blood clots or strokes?*
YesNo

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?*

What birth control have you used in the past?*
IUDsCondomsBirth control pillsWithdrawalEvra patchNuvaringDepo shot

What birth control would you like to use in the future?