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.

Hidden

Today's Date

DD slash MM slash YYYY

Last Name(Required)

First Name(Required)

Preferred Name

Pronouns

Saskatchewan Health Card #

Date of Birth(Required)

Address

Phone number(Required)

Is it safe to leave a voicemail here?

Yes

Email(Required)

Enter Email Confirm Email

1. When was your POSITIVE pregnancy test?

*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?

Are you certain of this date?

Yes

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

If 'Yes', specify type

4. Are you currently breastfeeding?

Yes

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

If 'Yes', explain

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

Yes

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

If 'Yes', explain

13. Have you ever had an operation?

Yes

If yes, list

14. Have you or anyone in your family had:

Blood clots in the legs or lungs?

Yes

If 'Yes', explain

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

Yes, explain

If 'Yes', explain

Serious reactions to anesthetics?

Yes, explain

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)