
At your intake appointment
Here's what we'll be discussing during your intake appointment. Go over it so you're prepared for the questions you'll have to answer.
Intake Appointment outline
Date: _______________
Confirm patient ID
Last Name: _______________ First Name: _______________
D.O.B.: _______________
HCN: _______________ VR: _______________
Address: ______________________________
City: _______________ Province: _______________
Postal Code: _______________
phone no.: ______________________________
Patient has received/read Pre-appointment information: Yes/No
Patient counselled on all options for pregnancy and requests virtual MA: Yes/No
General Patient history:
Age: ________ Weight: ________ Height:________ BMI: ___
PMH: _________________________________________________________
_________________________________________________________
_________________________________________________________
PObHx:
_________________________________________________________
_________________________________________________________
_________________________________________________________
PSxHx:
_________________________________________________________
_________________________________________________________
_________________________________________________________
Medication:
_________________________________________________________
_________________________________________________________
_________________________________________________________
Allergies:
_________________________________________________________
_________________________________________________________
Dating of pregnancy
LMP: _______________ (certain/uncertain)
quality of LMP c/w baseline menses: Yes/No
regular cycles: Yes/No
patient used hormonal contraception w/in past 2 months
Yes/No
Date of positive urine pregnancy test: ______________
molimial sx of pregnancy: (nausea/vomiting/breast soreness)
ultrasound this pregnancy available: Yes/No
if available: EDD by US __________________
Risk factors for ectopic pregnancy:
previous ectopic pregnancy yes/no
assisted fertility yes/no
indwelling IUD yes/no
symptoms: Pain: _________, PVB: __________, malaise:____________
Contraindications for MA:
allergy to mifepristone/misoprostol: Yes/No
uncontrolled asthma: Yes/No
ectopic pregnancy risks: Yes/No
hereditary porphyria: Yes/No
adrenal insufficiency: Yes/No
Long term oral steroids: Yes/No
Indwelling IUD: Yes/No
current medications interact with mifepristone/misoprostol: Yes/No
Hemorrhagic disorder/anticoagulation Yes/No
Anemia: Yes/No
if yes: Last hb: ________ Date: _____________
desired pregnancy: Yes/No
Safe environment/location for MA:
travel distance to nearest ER: __________ (<60 min)
travel distance to nearest US: __________
travel distance to nearest Lab: __________
home environment is safe with access to bathroom/privacy: Yest/No
Counselled on contraception: Yes/No
method chosen by pt: _______________________________________

After the initial INTAKE virtual appointment, you will have FOLLOW-UP appointments at 48-72 hours and 14 days. If there are any concerns arising in between these appointments, please do not hesitate to call the clinic or the doctor line.