Patient Attitude Survey
This Patient Attitude Survey was adapted from an MIC/MHRA survey.

Please take a moment to fill out this survey. Your answers will help us improve our services to you.

This survey is totally voluntary and anonymous. This means your name will not appear anywhere on the survey. If you decide not to participate, it will not affect the type of care that you receive at this clinic.

This survey is about medication abortion – when a woman is given pills to end her pregnancy, rather than having a procedure that involves instruments. A medication abortion is only done very early in pregnancy (within the first 9 weeks of pregnancy) and the woman passes the pregnancy tissue at home after using the pills.
1. How old are you? ______

2. What race do you consider yourself to be? Please mark one or more.

3. Had you ever heard of medication abortion (the abortion pill) before today?

4. Have you or has anyone you know ever had an aspiration abortion?

5. Have you or has anyone you know ever had a medication abortion (abortion pill)?

6. Do you feel that medication abortion (abortion pill) services are needed in this community or that this is something that the community does not need?

7. If they wanted an abortion, how many of your friends and neighbors do you think would use medication abortion services at this clinic?

8. Do you think this clinic should or should not provide medication abortion services?

9. If you needed an abortion, how likely would you be to use medication abortion services at this clinic?
10. What are the reasons that women in your community would want this clinic to provide medication abortions (abortion pill)? (Check all that apply)





11. What are the reasons that women in your community would not want this clinic to provide medication abortions (abortion pill)? (Check all that apply)





12. Even if you don’t plan to use medication abortion, if this clinic started to provide medication abortions, what would you do?




13. If this clinic offers medication abortion services, most people I know…







14. If I had the power to decide for this clinic, I would…. (choose only one)

Provide medication abortions at this clinic
Not provide medication abortions at this clinic

THANK YOU!

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These forms are not intended to provide legal, medical or other professional advice. They are not a substitute for consultation with a healthcare provider or for independent judgment by healthcare providers or other professionals regarding individual conditions and situations.