CARE Colorado MAP

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Phone Number

Area CodePhone Number
Email*
example@example.com
Would you like the pill to be delivered to your current address or a different delivery address?*

Delivered To My AddressDifferent Delivery Address
Proof of Identification*

Cancelof
What is your address?*

Street Address

Street Address Line 2

CityState

Zip Code
What is the delivery address?*

Street Address

Street Address Line 2

CityState

Zip Code
Height*
Weight*
Do you know the date of your last menstrual period?*

YesNo
When was your last menstrual period?*

MonthDayYear
Date
Did you have a positive pregnancy test?*

YesNo
Did you have an ultrasound(U/S) to confirm this pregnancy?*

YesNo
When was the U/S completed?*

MonthDayYear
Date
What was the Gestational age?
What was the due date?

MonthDayYear
Date
Do you have an IUD in place?*

YesNo
Did you ever have an ectopic or molar pregnancy?*

YesNo
Do you have any of the following: bleeding disorders, adrenal failure, allergies to mifepristone or misoprostol, or undergoing corticosteroid therapy. *

YesNo
Do you understand the risks of foregoing pre-procedure ultrasound? (Potential ectopic/molar pregnancy, Inaccurate pregnancy dating, Miscarriage) *

YesNo
Have you ever had any uterinesurgery? (cesarean section, fibroid removal, etc)*

YesNo
If you have gone through childbirth(whether vaginal birth or c-section) did you have heavy bleeding afterwards?*

YesNo
Did you receive a blood transfusion?

YesNo
We are sorry, but based on the information you have provided, you do not qualify for the abortion pill to be mailed to you, and will need to be seen in person. You may contact us directly by phone at 719-884-4070 to schedule an in person consultation for abortion services.
Patient Advocacy Questionnaire
Do you have a history of:

AnemiaBleeding/clottingEpilepsy/seizuresHeart problemsHeart murmursSTDs/Infectious DiseasesCold/Flu/Covid-19 Symptoms currentlyDepression/AnxietyAny prior surgeries. If yes, please explain
Do you have any known allergies?*

YesNo
What is the allergy?
Have you had any hospitalizations in the last 6 months?*

YesNo
When and why?
Do you have any medical problems or problems associated with this pregnancy that we should know about?*

YesNo
What problems do you have?
Total number of pregnancies*
Vaginal births
C sections
Abortions
Miscarriages
I still need time to think about my decision*

YesNo
I want to continue my pregnancy*

YesNo
Abortion is the best option for this pregnancy*

YesNo
Are you being forced or coerced into having this abortion today?*
While it is not their decision and this is your choice, is the person who got you pregnant, aware of your decision?*

YesNo
Is this person supportive of your decision?*

YesNo
We understand you may have thought about all of your options including adoption and/or parenting. Are you interested in resources about these options?*
There is no wrong way to feel after this abortion is complete. Do you have a support person you can talk to afterwards? If not, would you be interested in resources?*
Any additional questions or concerns you would like addressed?
Would you like to be screened for financial assistance?

YesNo
Social History

Questions are confidential and used for financial assistance purposes only
Marital Status
Employment Status
Highest Grade Completed
Type of Insurance
Are you currently receiving public assistance?

YesNo
Number of people in household
Monthly Gross Income (After Taxes)
Should be Empty:

Patient Advocacy Questionnaire

Social History