Date: _________________

Vitals: BP ____/____     Wt. ____     T ____     Hgb: ____/dl.

Urine pregnancy test: Positive/Negative or Sonographic confirmation:_____

Patient was counseled regarding her pregnancy options
Procedure explained, alternatives discussed, side effects,
       adverse events reviewed.
Informed consent obtained, filed in chart.

History:

LMP: Relevant gyn history:

Last PAP:

G ____ P: ___ # of C/S: ___ Previous abortions: ___ Surg ___ Med___ SAB

Rh Type: _____ by pt. Hx / by documentation

Ultrasound Exam:

GS:  _____ mm
CRL: _____ mm
Gestational Age ___________
FHR: Y/N      YS: Y/N      WNL/Notes:

Assessment:

Patient is candidate for aspiration abortion
Misoprostol 400mcg. Given buccally at _______
800 mg Ibuprofen dispensed for oral administration. Time: _________
Other: ________________________________________________
Labs drawn or Rh status confirmed.
Post procedure contraception:_______________________________

Clinician Signature: ______________________________________________