REPORT OF
INDUCED TERMINATION OF PREGNANCY
Information is PRIVATE and CONFIDENTIAL
Facility
use only
1. Patient’s ID number:
2. Date termination performed:
/
/
(Patient ID/Facility Chart/Case No.)
3. Patient’s age:
(Month/Day/Year)
4. Patient’s residence address:
(County)
(City)
5. Date last normal menses began:
/
Facility
use only
/
(Month/Day/Year)
6. Clinical estimation of gestational age:
Completed weeks
7. Previous live births (enter a number or “none”): 8. Previous terminations (enter a number or “none”):
a. Live births now living:
a. Spontaneous Abortions, Miscarriages, Stillbirths, Fetal Deaths:
b. Live births now dead:
b. Induced Abortions (Do NOT include this termination):
9. Marital status:
10. Education:
Never Married
Separated
Now Married
Declaration of Oregon Registered Domestic Partnership
Divorced/Dissolution of Domestic Partnership
Widowed
8th grade or less; none
9th-12th grade; no diploma
High school graduate or GED
Some college credit, but no degree
Associate’s degree
Bachelor’s degree
Unknown
Master’s degree
Doctorate or professional degree
Unknown
11. Patient’s race (select one or more):
White
Black or African American
American Indian or Alaska Native
(specify tribe(s)):
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (specify):
Native Hawaiian
Samoan
Guamanian or Chamorro
Other Pacific Islander (specify):
Other (specify):
12. Was birth control being used at the time patient became pregnant?
If yes, specify method(s) below (check all that apply):
Birth Control Pill
Hormone Implant
Non-surgical sterilization; e.g., Essure
Yes
IUD/IUC
Patch
Emergency Contraception
No
Unknown
Condoms, Prophylactics
Rhythm
NuvaRing
Contraceptive Injection; e.g., Depo-Provera
Other (specify):
13. Name of facility where termination occurred:
14. Location of termination:
(County)
(City)
15. Primary procedure that terminated this pregnancy (check only one):
Suction Curettage
Medical – Mifepristone
Other medical (Non-surgical); specify medication(s):
Dilation and Evacuation (D & E)
Vaginal Prostaglandin
Sharp Curettage (D & C)
Hysterotomy/Hysterectomy
Other (specify):
16. Other procedures used for this termination (check all that apply):
Suction Curettage
Medical – Mifepristone
Other medical (Non-surgical); specify medication(s):
Dilation and Evacuation (D & E)
Vaginal Prostaglandin
Sharp Curettage (D & C)
Hysterotomy/Hysterectomy
None
Other (specify):
17. Was follow-up visit recommended?
Yes
No
18. Was post-operative/after-care information provided?
19. Were there complications at the time of the procedure?
If yes, specify complications (check all that apply):
Hemorrhage
Infection
Retained products
Failure of first method
Yes
Infection
Failure of first method
No
No
Uterine perforation
Other (specify):
20. At time of completion of this report, had follow-up visit occurred at this facility?
If yes, specify complications (check all that apply):
21. Complications:
None
Hemorrhage
Retained products
Yes
Cervical laceration
Yes
Uterine perforation
Other (specify):
No
Unknown
Cervical laceration
- I have read and fully understand the contents of this form.
- I certify that this information is true and correct to the best of my knowledge. I will notify you if any changes occur. I hereby
consent and give my permission to the doctor (and the doctor assistants) to administer and perform such procedures upon me as
the doctor deems necessary in the course of my treatment in this clinic.
SIGNATURE: ________________________________DATE:________