Provide Two-Week Follow-Up Assessment

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ABORTIONS
PRICING
ABOUT US
PATIENT CENTER
Español

Thank you for following up with us regarding your recovery and return to wellness after receiving care at Falls Church Healthcare Center.

Please provide us an update about your recovery using the form below, or call us at 703-532=2500 to speak with one of our nurses. You can also indicate on this form any specific concerns or questions you may still have and we will be happy to call you back. Please do not hesitate to call us if you would like to discuss your concerns. We are here to serve you.

Note: You’ll notice that we are not asking you to take a urine pregnancy test at this time. Instead, you will be taking the pregnancy test in another two weeks. If the test at that time is positive, we will ask you to report this to us at that time and set up an appointment with us to come in.

Online Self-Assessment at 2 Weeks

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Staff

Name*

First Last

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Today's Date

MM slash DD slash YYYY

Date of Birth*

Month

Day

Year

Phone*

May we leave a message?*

Yes

No

Email

Prefered Method of Contact:*

Phone

Email

Follow-Up Evaluation

Date of your procedure*

Month

Day

Year

Type of Abortion*

Medication Abortion (Abortion Pill)

Procedural Abortion - Awake or Asleep

Not sure

Tell us about your recovery:

How are you feeling now?*

Do you have any continuing concerns?*

Tell us about your post-procedure bleeding and discharge

Number of days you bled*

Color of Bleeding*

Red

Pink

Brown

Mixture of All

Other

Are you still bleeding?*

Yes

Just spotting

No

Did you have clots?*

Yes

No

How often did you have clots?*

Size of clots*

(e.g. peanut sized, grape sized, lemon sized, etc.)

Did you have any other vaginal discharge?*

Yes

No

Please describe further if needed:

Was there odor?*

Yes

No

Additional Questions:

Do you still have nausea?*

Yes

No

Comments

Do you still have breast tenderness?*

Yes

No

Comments

Can we assist you with contraception or GYN wellness? (FCHC recommends an annual wellness exam.)*

Yes

No

I would like a prescription for birth control

Name of Pharmacy

Pharmacy Phone number

Would you like us to contact you?*

Yes

No

Can we help you with any other concerns?*

Yes

No

How can we help you?*

STAFF INITIALS