Name:_______________________________

Medical Record #:  _______________________________

Prior to Medication abortion

hormonal contraception (Past 3m)
uncertain LMP
irregular cycles/cycle length>35d
cost/logistical issues
teaching
size-date discrepancy
IUD at follow up
   bleeding
   8 weeks or greater by LMP

Post Medication abortion
Pre Aspiration abortion
Post Aspiration abortion

Prenatal

hormonal contraception (Past 3m)
uncertain LMP
breastfeeding
irregular cycles/cycle length >35d
1st tri bleeding/threatened abortion
teaching
size-dates discrepancy

IUD localization
Other ___________________________

FINDINGS:

Gestational Sac ____________mm (MSD)
CRL___________mm
Yolk Sac
Fetal Heart
Other ___________________________

Scan

  ___________________________________
  Provider Signature

  ___________________________________
  Date