[Your Health Center Name Here]

Date: ______________

LMP: ______________    Regular   Y____ N____

Was using contraception?   Y____ N____

Previous pregnancies ________________________________________________

Allergies: _______________________        Blood type: _____________________

Contraceptive preference: ____________________________________________     

Patient phone numbers    Home: _______________       Work: ________________   

                                       Cell: _________________      Other: ________________


Physical Examination    Ht.                Wt.                  BP                     P

Speculum exam ____________________________________________________

Bimanual exam ____________________________________________________     

Estimated gestational age ______________        consistent with dates Y____ N____



_______ Has received patient education materials and instruction sheet

_______ Has agreed to procedure and has signed consent form


Pre-procedure medication:

Acetaminophen 1000mg. PO __________________________________________

Ibuprofen 800 mg PO _______________________________________________


Procedure Note: After cleaning the external genitalia with betadine, a sterile speculum was inserted into the vagina. The cervix was cleaned with betadine, and parcervical block was administered with _____cc of lidocaine 1%. A tenaculum was applied to the cervix, and dilatation was performed up to a _____ Pratt. A _____ dilator was inserted into the uterus and products of conception were removed by suction aspiration. The tenaculum and speculum were removed and the patient was in ______________ condition.


Post-procedure observation:

Time            BP                Pulse       Other

_______     ____/___     _____     _____________________________________

_______     ____/___     _____     _____________________________________

_______     ____/___     _____     _____________________________________


Post-procedure medication:

Rhogam IM in office ________________________________________________

Depo-provera 150 mg IM ____________________________________________


Serial labs and tests

Date Urine HCG Serum HCG Hct/Hgb Ultrasound Other


Follow-up Visits and Calls

Date Notes (sign each one)


Final Disposition

____TOP successful; contraception prescribed ______________________________

Patient will return for follow-up visit on _________ at ____ AM/PM with __________

Signed: _______________________________________        Date: ___________