Patient Follow-Up & Survey Patient Follow Up & Survey for FCHC patients Name* First and Last Name Date of Birth MM slash DD slash YYYY Prefered Method of Contact:* Phone Email Follow-Up EvaluationDate of Procedure or Pills:* MM slash DD slash YYYY Tell us about your recovery:How are you feeling now?*Do you have any concerns?*Tell us about your bleeding:Number of days of bleeding*Color of Bleeding Red Pink Brown Mixture of all Are you still bleeding?* Yes Just spotting No Did you have clots?* Yes No How often did you have clots?*Size of clots*(Dimes, quarters, lemons, grapefruit)Did you have any other vaginal discharge?* Yes No Was there odor?* Yes No Please describe further if needed:Additional Questions:Do you still have nausea?* Yes No Please describe further if needed:Have you had sexual intercourse since the abortion?* Yes No Please note that your fertility returns immediately after an abortion and you can get pregnant again quickly if you have unprotected sex.Can we assist you with any concerns, contraception or GYN wellness?* Yes No If prescription for contraception is requested, please provide the type (pills, patch, ring) and pharmacy information. Or, please write if you would like to schedule an IUD or Nexplanon implant.Birth control type, Pharmacy Address and Phone NumberCAPTCHA
