Pre Abortion Medical History Form

CONFIDENTIAL . . . . . . . MEDICAL HISTORY FORM . . . . . . . CONFIDENTIAL

Used for Pregnancy Testing & Counseling (To be filled in only by counselor)

Date:_______________ Prior Date:_______________ Prior Chart No:______________

Last Name:___________________________ 1st Name:___________________ MI:_____
Address:___________________________ City:_______________ State:___ Zip:______
Age:___ DOB:__________ Race:____ Marital Status: Sngl___ Engaged___ Mar___ Sep___
Divorced___ (Is your fiance / husband / former husband the father of the child? Yes___ No___ )
Where are you employed?_______________________________________
Where do you go to school?______________________________________
How many years of schooling have you completed?___________________
Work Phone:___________________ Home Phone:____________________
May we call you at home?____ If not, how?_________________________

How did you hear about us? Yellow Pages under: Birth Control___ Clinics___ Clinics-Medical___ Pregnancy Counseling___ Friend___ Aborters of Babies___ Assassins___ Other____________

What religion do you claim (denomination)?_________________________
Within the past twelve months, how often have you attended church?
Weekly___ Bi-weekly___ Monthly___ Per year________ Other_________________

If test indicates that you are pregnant, what is your intention?
Abortion____ or Birth____ Undecided____ Adoption____ or Keep____ or Other_________

PREGNANCY DATA

1. On what date did you start your last menstrual period?_________________
A. Was this period: Normal____ Lighter than normal____ Heavier than normal____
B. Are your periods normally: Regular_____ Irregular_________________
C. Any spotting or *persistent bleeding since your last period: Yes___ No___
(If so) How much?_________________________________________
2. Check current birth control method: NFP___ Condom___ Withdrawal___ *IUD___ Pills___ Diaphragm___ Foam___ Gel___ None___ Other_________________
3. Has either you or your partner ever undergone a sterilization procedure?____
If so, type?_______________________________
4. Were you planning a pregnancy at this time? Yes____ No____ Indifferent_____
5. Have you ever been pregnant before? Yes(#)___ No___ If YES please indicate # of:
Previous live births (dates)________________________________________________
Previous abortions (dates)________________________________________________
Previous miscarriages (dates)______________________________________
or *tubal pregnancies (dates)______________________________________
6. Check symptoms you've noticed lately: Fatigue____ Increased Urination____ Nausea____ Tender breasts____ Weight change (amount)__________ Other___________________
7. Since certain legal & illegal drugs, pain killers and medications can interfere with the results of the pregnancy test, we need to know what you have taken within the last 48 hours, both prescription and non-prescription:_____________________________________
8. Have you had, or do you now have, or think you may now have gonorrhea, syphilis, AIDS or any other sexually transmitted disease? ____ If yes, what?__________________________
9. Do you have any current or *continuing medical problems: __________________________
*THESE are CONDITIONS which may indicate an abnormal pregnancy. Any client who indicates that she has one of these conditions, is to be REFERRED to a specialist for evaluation.

Before or after showing videos, please fill in SURVEY FORM as needed.

Filled in: Yes___ No___

EDUCATIONAL VIDEOS USED: Eclipse of Reason/26__ One in a Million/17__ Let Me Live/5__ A Better Way(rape)/29__ A Special Kind of Love(adoption)__ A Matter of Choice/28__ Assignment Life/52__ Conceived in Liberty/59__ Silent Scream/28 Engl__ Span__ Aching Heart__ Baby Choice/10__ Before You Were a Baby__ Chastity/30__ Dating, Teen-Aid__ Higher Laws__ Living Experiments__ Miracle of Ultra Sound/15__ No Alibis/38__ Pro-Life Doctors Speak Out/15__ Rising to the Challenge/27__ Say Yes to Love, No to Sex__ Shelley Madden__ Teens & Abortion/30__ Why Wait__ Window to the Womb/12&7__ You & Your Pregnancy/20 __ Youth, Sex & Chastity__ Your Crisis Pregnancy/25__

EXTRA people above age of reason who saw film(s):____ Male:____ Female:____

RESULTS: No time for film (do not do test)___ Refused film (do not do test)___ Displayed anger___ Cried during film &/or interview___ Left happy___ Left sad___

AFTER the client has been counseled, what is she considering? Abortion___ or Birth___
Undecided___ Adoption___ or Keep___ or Other___________________
If still abortion minded or undecided proceed with Claim Release & Disposal Authorization forms.

IMPORTANT: IF client indicates prior abortion(s), have you initiated Post Abortion Syndrome counseling? Yes___ No___ Referred to:__________________________

AFTER you have taken care of the physical problem(s) facing the client, that of whether she has a positive or negative test, then complete the following information:
Would you like to be on our mailing list? Yes___ No___
Would you be interested in joining a support group? Yes___ No___
How do you feel about what you have now learned? ________________________
Was client given a "Mothering Packet"? Yes___ No___
Has client been given pamphlets on "Abortion's Mental Problems", etc.? Yes___ No___

TEST RESULTS

Was precipitate visible in urine?_______ Was urine turbid?_______ Was urine filtered?________
Rack Slot Number?___ Time test started?__________ Time results observed?_________
Positive_______ Negative_______ Inconclusive_______ Retest suggested________
Follow up appointments, if any, should not be in less than 10 days if menses has not yet started.
Date:__________________ Time:________________

Counselor:_________________ Referred to:_________________________

NOTES: Freely use helpful imagination during interview. Use margins for notations. Pregnancy tests normally are not to be done on women or girls who refuse to see films or be properly interviewed.

COMMENTS:

Current Chart No:________________________ Survey Form____________
CR Form____________ DA Form____________

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