Medical abortion at a distance Questionnaire.
Please only complete if you have been given a chart number and have been instructed to do so by office staff.
This is not a booking form

Initials Chart # *
(Note: chart number is given to you over the phone by Willow staff)
What was the first day of your last normal menstrual period??
(mm / dd / yy)
What form of birth control were you using when you got pregnant? (including condoms, counting safe days, withdrawal, etc)
Have you ever been pregnant before?   Yes    No
How many: Births   Abortions   Miscarriages  
Any complications or problems with previous pregnancies?   Yes    No
If yes, what kind?  
Do you take any regular medications ?   Yes    No
If yes, what kind?  
Do you have any medical illnesses like asthma, diabetes,liver or kidney disease, migraines?   Yes    No
If yes, what kind?  
Are you allergic to any medications?   Yes    No
If yes, what kind?  
Have you ever had surgery before?   Yes    No
If yes, what kind?  
Do you smoke?   Yes    No
# of cigarettes each day  
Do you use recreational drugs (marijuana, ecstasy, cocaine, etc.) or herbal medicines?   Yes    No
Which ones and how much?  
Has any of your family members under the age of 50 had blood clots or strokes?   Yes    No
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 kind of birth control methods have you used in the past?
Condoms    Diaphragm  
Birth Control Pills   Depo Provera  
Rhythm (counting safe days)   Withdrawal (pulling out)  
IUD  Others
What kind of birth control method would you like to use in the future?
We calculate your dose of methotrexate by using your height and weight
Weight  Pounds /    Kg
Height   ft /   in  /    cm
Counselling Questionnaire:
I have been able to talk about my decision to have an abortion with:
My partner/husband/boyfriend:
I feel that:
My main concerns are:
Whose decision is it for you to have this abortion?
How anxious do you feel on a scale of 0 to 10 where 0 is not anxious at all and 10 is the most anxious you have ever been?
How depressed do you feel on a scale of 0 to 10 where 0 is not depressed at all and 10 is the most depressed you have ever been?
Is there anything else the counsellor should know about you to give you the support you need?
Do you want a counselor to email you after your abortion to see how you are doing?   Yes    No
E-Mail Address

Suite 1013 – 750 West Broadway Vancouver BC V5Z 1H9
Ph. : 604-709-5611
Fax : 604-873-8304