Early Pregnancy Assessment Clinic appointment request
Required information:
First name:
Last name:
Date of birth:
Phone:
Optional questions:
Why are you requesting an appointment in EPAC?
Please choose
Bleeding
Pain
Follow up from ER or other provider
Previous miscarriage
Previous ectopic pregnancy
Other
Have you had a positive home pregnancy test?
Yes
No
If yes – when?
What was the first day of your last period?
How many times have you been pregnant?
Please choose
1
2
3
4
5
6 or more
Do you have any children?
Yes
No
If yes – how many?
Please choose
1
2
3
4
5
6 or more
Have you had any miscarriages?
Yes
No
If yes – when was the last one?
Have you had an ectopic pregnancy (pregnancy not in the uterus)?
Yes
No
If yes – when?
What was the treatment?
Are you currently on any kind of birth control?
Yes
No
Are you having any bleeding?
Yes
No
If yes, options are:
Please Choose
Spotting
Light
Medium
Heavy
Are you having any pain?
Yes
No
If yes – where?
Please rate your pain: (10 being the most pain)
Please choose
1
2
3
4
5
6
7
8
9
10
Who is your regular OBGYN?
Please list your blood type if known.
Please Choose
O-
O+
A-
A+
B-
B+
AB-
AB+
Have you had an ultrasound or any other testing done for this pregnancy?
Yes
No
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