CARE Colorado MAP

Name*

First NameLast Name

Date of Birth*

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*

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*

Blood Type

Do you know the date of your last menstrual period?*

YesNo

When was your last menstrual period?*

Date

Did you have a positive pregnancy test?*

YesNo

Date of conception (if known) :

Current contraception method used (if any) :

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

YesNo

When was the U/S completed?*

Date

What was the Gestational age?

What was the due date?

Date

Date of Last Delivery?

Date

Did you ever have an ectopic or molar pregnancy?*

YesNo

If yes, when:

Do you have an IUD in place?*

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.

Do you have a history of:

If any marked yes, please explain:

History of Drug/Alcohol Abuse:*

YesNo

Current Smoker?*

YesNo

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?

List any additional medical health problems or recent hospitalizations:

Are there any complications or problems associated with this pregnancy:*

YesNo

What problems do you have?

Any problems with anesthetics?

List current medications:

Total number of pregnancies*

Still Birth (20+ weeks):

Vaginal births

C sections

Abortions

Miscarriages

Hospital and date of most recent c-section:

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

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)

Text Messaging and Opt-Out Policy
By providing your phone number and opting in to receive text messages from our company, you consent to receive SMS and MMS messages regarding your account, services, promotional offers, or other relevant information. Message frequency may vary.

Opt-Out:
You can opt out of receiving text messages from us at any time. To stop receiving messages, simply reply "STOP" to any text message you receive from us. After opting out, you will no longer receive text messages unless you re-enroll by contacting us or providing express consent again.

Message and Data Rates:
Standard message and data rates may apply to any text messages sent or received, depending on your mobile carrier's plan.

Privacy and Patient Information:
We are committed to protecting your privacy and the confidentiality of your patient information. By opting in, you agree to the use of your information solely for the purpose of communication related to your healthcare and services.

Patient Advocacy Questionnaire

Social History