1.

FACILITY NAME (if not clinic or hospital, give address)

2.

COUNTY OF PREGNANCY

TERMINATION

3.

PATIENTS IDENTIFICTION NO.

4a.

RESIDENCE – STATE

4b.

COUNTY

4c.

ZIP CODE (Chicago only)

5.

PHYSICIAN'S LICENSE NO.:________

6.

AGE LAST BIRTHDAY

7.

MARRIED?

8.

DATE OF PREGNANCY

 Yes

 No

TERMINATION (month, day, year)

9a.

RACE/ETHNIC

9b.

ETHNIC

10.

EDUCATION

(Specify only highest grade completed)

11.

CLINICAL ESTIMATE

OF GESTATION (Weeks)

Native American

Hispanic:

Black

Yes

Elementary/Secondary

College

White

No

(0-12)

(1-4 or 5+)

Asian

Other (Specify)_________________

12.

PREVIOUS PREGNANCIES (Complete each section)

LIVE BIRTHS

OTHER TERMINATIONS

12a.

Now Living

12b.

Now Dead

12c.

Spontaneous

12d.

Induced

(Do not include

this termination)

Number______

Number______

Number______

Number_____

None

None

None

None

13.

Rh DETERMINATION

14.

IF Rh NEGATIVE ANTI-Rh

15.

REASON FOR TERMINATION

Rh Pos.

Given

Patient's Request

Rh Neg.

Not offered to patient

Other

Not Done

Refused by patient

Medically not indicated

16a.

PROCEDURE THAT TERMINATED PREGNANCY

TYPE OF TERMINATION PROCEDURES

16b.

ADDITIONAL PROCEDURES USED FOR THIS TERMINATION, IF ANY

(Check only one)

(Check all that apply)

Suction Curettage

Sharp Curettage

Dilation and Evacuation (D&E)

Intra-Uterine Saline Instillation

Intra-Uterine Prostaglandin Instillation

Hysterotomy

Hysterectomy

Other (Specify)______________________

17.

COMPLICATIONS OF PREGNANCY TERMINATION?

Yes

No

If Yes, Mark All That Apply

HEMORRHAGE

ANESTHETIC

UTERINE PERFORATION

RETAINED PRODUCTS

CERVICAL LACERATION

DEATH

INFECTION

OTHER, SPECIFY

18.

HOSPITALIZATION REQUIRED AS A RESULT OF COMPLICATION:

Yes

No