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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.

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