MENUMENU

Home
Downtown Clinic
Pharmacy
Westside Clinic
Foundation
Resources
- Health Information Resources
- Community Resources
Publications
Become Involved
About Us
Contact Us
Search
Menu Menu

Abortion Intake Form

Once you have an appointment with us booked, please complete the form below and click Submit. The Health Information Management team will receive your request. Please DO NOT PRINT this page.

This field is hidden when viewing the form

Today's Date

DD slash MM slash YYYY

Last Name(Required)

First Name(Required)

Preferred Name

Pronouns

Saskatchewan Health Card #

Date of Birth(Required)

DD

MM

YYYY

Address

Phone number(Required)

Is it safe to leave a voicemail here?

Yes

No

Email(Required)

Enter Email Confirm Email

1. When was your POSITIVE pregnancy test?

DD

MM

YYYY

*If you have not done a home urine pregnancy test, this is required prior to your visit. If you don’t have access to a home pregnancy test this can be done in our office – please ask the receptionist.

2. When was the FIRST day of your last NORMAL period?

DD

MM

YYYY

Are you certain of this date?

Yes

No

Are your periods regular and predictable?

Yes

No, explain

If 'No", explain

3. Were you using a method of hormonal birth control or Plan B at any time since your last period?

Yes

No

If 'Yes', specify type

4. Are you currently breastfeeding?

Yes

No

5. Have you experienced any of the following symptoms in this pregnancy? Select all that apply.

Vaginal Bleeding

Severe or one-sided pelvic pain

Pelvic pain with shoulder tip pain

Severe vomiting and/or unable to keep fluids down

Foul smelling vaginal discharge with fever or pelvic pain

None of the above

6. Do any of the following apply to you?

Intrauterine Device (IUD) currently in place

Previous ectopic pregnancy

Previous or current Pelvic Inflammatory Disease (PID)

Previous tubal surgery or “tubes tied”

Pregnancy achieved using reproductive technology

None of the above

7. Which option(s) are you considering for this pregnancy? If you have any questions, please see the documents linked on our website detailing the options. We will also discuss further during our visit.

Continue with pregnancy

Continue with pregnancy options

With Parenting

With Adoption

7b. Which option(s) are you considering for this pregnancy?

Terminate pregnancy

7. Continue with pregnancy termination options

With Medication

With Surgery

8. Do you have allergies?

Yes

No

If 'Yes', explain

9. Are you on any medications (prescription or over the counter), inhalers, vitamins, or herbal supplements?

Yes

No

If 'Yes', list

10. Have you had any of these medical conditions? (check all that apply)

Chronic adrenal failure (i.e. Addison’s disease, also called adrenal insufficiency)

Severe or uncontrolled asthma requiring regular use of oral or inhaled steroids

Inherited porphyria

Rh negative blood type (i.e. A neg, B neg, O neg, Ab neg)

Anemia or Thalassemia

Bleeding disorder (Hemophilia, von Willebrand Disease)

Current use of blood thinners (warfarin, apixaban, aspirin)

Current use of systemic corticosteroid medication (i.e. prednisone, dexamethasone)

Seizure Disorder

None of the above

11. Do you have any other medical conditions? List all medical conditions and diagnoses and year of diagnosis (i.e. Anxiety – 2011, abnormal pap – 2015)

12. Have you ever had an iron infusion or blood transfusion?

Yes, please explain

No

If 'Yes', explain

13. Have you ever had an operation?

Yes

No

If yes, list

14. Have you or anyone in your family had:

Blood clots in the legs or lungs?

Yes

No

If 'Yes', explain

Bleeding disorders (ie. hemophilia, von willebrand’s)?

Yes, explain

No

If 'Yes', explain

Serious reactions to anesthetics?

Yes, explain

No

If 'Yes', explain

15. Obstetrical History: Please list how many of each of the following and explain any complications.

Number of pregnancies in total (including this one)

Complications (including hemorrhage):

Number of Term Births (>36 weeks)

Complications (including hemorrhage):

Number of Preterm Births (<36 weeks)

Complications (including hemorrhage):

Number of Miscarriages

Complications (including hemorrhage):

Number of abortions (including medication and surgical)

Number of medication abortions

Complications (including hemorrhage):

Number of surgical abortions

Complications (including hemorrhage):

Number of tubal or ectopic (outside the uterus)

Complications (including hemorrhage):

Number of Vaginal Deliveries

Complications (including hemorrhage):

Number of C-Sections

Complications (including hemorrhage):

16. What birth control methods have you used in the past? (describe any problems)

Birth Control Pills

Describe any problems - Birth Control Pills

16. What birth control methods have you used in the past? Nuvaring vaginal ring

Nuvaring vaginal ring

16. Describe any problems - Nuvaring vaginal ring

16. What birth control methods have you used in the past? Evra patch

Evra Patch

16. Describe any problems - Evra Patch

16. What birth control methods have you used in the past? Depo-Provera injection

Depo-Provera injection

16. Describe any problems - Depo-Provera injection

16. What birth control methods have you used in the past? Nexplanon insertion

Nexplanon insertion

16. Describe any problems - Nexplanon insertion

16. What birth control methods have you used in the past? IUD, Copper or Hormones

IUD, Copper or Hormones

16. Describe any problems - IUD, Copper or Hormones

16. What birth control methods have you used in the past? Condoms

Condoms

16. Describe any problems - Condoms

16. What birth control methods have you used in the past? Morning after pill/Plan B

Morning after pill/Plan B

16. Describe any problems - Morning after pill/Plan B

16. What birth control methods have you used in the past? Tubal ligation/Vasectomy

Tubal ligation/Vasectomy

16. Describe any problems - Tubal ligation/Vasectomy

16. What birth control methods have you used in the past? Other

Other

Describe any problems - Other

16. What birth control methods have you used in the past? None

None

16. Describe any problems - None

17. What birth control method, if any, do you want to use in the future?

18. Should you require a surgical abortion, the following information (18 a-f) is important for us to know:

18a. What is you current weight?

(imperial, example: 135 lbs)

What is you current height?

(imperial, example: 5 feet 4 inches)

18b. Do you drink alcohol?

Yes, type/how often?

No

If 'Yes', type/how often?

18c. Do you use nicotine/smoke cigarettes?

Yes, how much/how often?

No

If 'Yes', how much/how often?

18d. Do you use cannabis?

Yes, how much/how often?

No

If 'Yes', how much/how often?

18e. Do you use street drugs?

Yes, type/how often?

No

If 'Yes', type/how often?

18f. Do you have a history of substance abuse or dependence?

Yes, explain

No

If 'Yes', explain

19. If you have decided, what is your choice for this pregnancy?

Continue with pregnancy

19. Continue with pregnancy options

With Parenting

With Adoption

19b. Which option(s) are you considering for this pregnancy?

Terminate pregnancy

19b. Terminate pregnancy options

With Medication

With Surgery

19. Unsure

Unsure

20. My feelings about my pregnancy choice are:

I am firm and certain in my decision

I have some conflicts with my decision

I have serious conflicts with my decision

21.

I confirm this pregnancy choice is my own, without force or coercion.

22. Do you have support (i.e. Partner, family, friends, counsellor, other?)

Yes

No

23. Is this pregnancy the result of a sexual assault?

Yes

No

Prefer not to say

24. Would you like to meet with a professional counselor to help you with your feelings about your pregnancy, your options, or your decision?

Yes

No

25. Do you agree to your health information from this visit being shared with your primary care provider (i.e. your family doctor or nurse practitioner)?

Yes

No

No primary care provider

If yes, provide their name and clinic phone number

26. Is there any additional information you would like us to know?

27.

I understand that if I don't complete the follow-up labs as scheduled and the clinic can't get in touch with me after three phone calls within five business days, they will send a letter to the address I provided. This letter will include a lab request and a reminder to follow up as originally planned.

Completed by:

Completed by Self

Self

Completed by Interpreter

Interpreter

Completed by Interpreter enter name

Completed by RN/Dr.

RN/Dr.

Completed by RN/Dr. enter name

Completed by Other

Other

Completed by Other enter name

By checking this box, I am electronically signing this form(Required)

By checking this box, I am electronically signing this form

By checking this box, I confirm this information is accurate and complete(Required)

By checking this box I confirm this information is accurate and complete

Phone

This field is for validation purposes and should be left unchanged.

Downtown Clinic

455 – 2nd Avenue North
Saskatoon, SK S7K 2C2
Telephone: 306-652-0300
Fax: 306-664-4120
PHARMACY: 306-664-4277

follow me on facebook

Westside Clinic

1528 – 20th Street West
Saskatoon, SK S7M 0Z6
Telephone: 306-664-4310
Fax: 306-934-2506
PHARMACY: 306-986-2906

2211 11th Street West

Telephone: 306-664-4283
Counselling and Occupational Therapy
(temporary location while we address the Langer Building issues)

The Saskatoon Community Clinic respectfully acknowledges that we are situated on Treaty 6 territory and traditional lands of First Nations and Métis people.

© 2020 | Privacy Statement | Website Terms of Use | Social Media Terms of Use