Medication Abortion Follow Up Survey

Question Title

* 1. What was the date of your appointment?

DD/MM/YYYY

Date

Question Title

* 2. When did you pass the pregnancy tissue?

After taking the Mifeprex

After inserting the misoprosotol

Other (please specify)

Question Title

* 3. How long after taking the medication did it take to pass the pregnancy tissue?

1-4 hours

5-10 hours

11-16 hours

16 - 24 hours

more than 24 hours

more than 48 hours

Question Title

* 4. Please rate any discomfort experienced during the non-surgical abortion procedure on a scale of 1-10, with 1 being comfortable, no pain at all; and 10 being excruciating, hardly bearable.

Question Title

* 5. If you did experience discomfort, how would you describe it?

cramping lighter than a menstrual period

cramping similar to a menstrual period

cramping stronger than a menstrual period

severe cramping

Other (please describe)

Question Title

* 6. Did you experience any of the following side effects during your non-surgical abortion?

nausea

vomiting

diarrhea

elevated temperature

Other (please specify)

Question Title

* 7. Regarding your non-surgical abortion experience, would you recommend this method or a surgical abortion?

Medical abortion

Surgical abortion

Please explain why.

Question Title

* 8. Please check the answer(s) that best describe your post-abortion bleeding:

no bleeding

spotting only

less than a normal period

same as a normal period

more than a normal period

bleeding or spotting with intervals between

one episode of heavy bleeding

continuous

Other (please specify)

Question Title

* 9. How many days did you bleed or spot altogether?

1-3

4-6

one week

8-10

11-13

two weeks

more than 2 weeks

Question Title

* 10. If you had cramps on the days following your abortion, please check all that apply.

mild to no cramping

like my normal period

worse than normal period

prevented me from doing my normal activities

I took pain medication to help with discomfort

Other (please specify)

Question Title

* 11. Have you had a post-abortion check-up?

YES

If yes, where did you go for check up?

Question Title

* 12. Have you experienced any doctor-confirmed abortion-related complications?

YES

Please tell us what happened and where you were seen.

Question Title

* 13. How informative was the discussion of birth control you had with your advocate or the recovery room attendant?

very informative

somewhat informative

not informative

neither discussed birth control with me

I knew what I wanted and did not need more information

Comment

Question Title

* 14. Are you currently using or planning to use birth control?

YES

UNSURE

Question Title

* 15. If yes, what method?

birth control pill

sponge

permanent sterilization (TL, vasectomy)

condoms

abstinence

MPAR/Depo

withdrawal

the patch

diaphragm

IUC/IUD

vaginal ring

Why did you choose this method?

Question Title

* 16. Please check those responses that best fit your decision to have an abortion:

I am satisfied I made my decision as I did.

It was a positive experience for me.

I feel a bond with other women because of the experience.

It was a negative experience for me, but I do not regret my decision.

I regret my decision.

I have mixed feelings because

Question Title

* 17. My general feeling about the Emma Goldman Clinic is:

very positive

positive

neutral

negative

very negative

Other (please specify)

Question Title

* 18. Were you satisfied with the interactions you had with clinic staff?

YES

Please comment

Question Title

* 19. Do you have any feedback or suggestions you would like to give us?

Question Title

* 20. How did you find out about the Emma Goldman Clinic? (check all that apply)

Word of mouth

Yellow pages

Dr.'s office or clinic

Poster or flyer

Emma Goldman Clinic website

Other website

Newspaper ad

High School Newspaper

Other (please specify website or newspaper)

Question Title

* 21. Did you use an internet search engine?

YES

Which one(s)

Question Title

* 22. The following information is optional.

Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Question Title

* 23. Do you have any comments about your experience that we could share with our supporters, politicians and/or in our clinic newsletter? Your name will not be used.