HomeMy WebLinkAboutIdaho Induced Termination
HWH-0135
(1-13) Submit directly to: Vital Statistics Submit directly to: P.O. Box 83720 Submit directly to: Boise, Idaho 83720-0036 TYPE/PRINT
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State of Idaho
REPORT OF INDUCED TERMINATION OF PREGNANCY State File No. _______________________
1. FACILITY NAME (if not clinic or hospital, give address) 2. CITY, TOWN, OR LOCATION OF
2. PREGNANCY TERMINATION
3. COUNTY OF PREGNANCY
3. TERMINATION
4. PATIENT’S IDENTIFICATION CODE 5. AGE LAST BIRTHDAY
(if under 18, you must complete item #19)
6. MARRIED? (At termination, conception, 6. or any time between)
YES NO
7. DATE OF PREGNANCY
7. TERMINATION (Mo, Day, Yr)
8a. RESIDENCE - STATE 8b. COUNTY 8c. CITY, TOWN, OR LOCATION 8d. INSIDE CITY LIMITS?
YES NO
8e. ZIP CODE
(First five digits only)
9. OF HISPANIC ORIGIN? (Specify No or Yes- 9. if yes, specify Cuban, Mexican, Puerto Rican, etc.)
NO YES
9. Specify: _____________________________
10. RACE - American Indian, Black, White,
10. Japanese, etc. (Specify below)
11. EDUCATION
(Specify only highest grade completed)
Elementary/Secondary (0-12) College (1-4 or 5+)
12. DATE LAST NORMAL MENSES BEGAN 12. (Month, Day, Year)
13a. CLINICAL ESTIMATE OF GESTATION (Weeks)
(See question #20 for additional information)
13b. METHOD OF DETERMINING GESTATIONAL AGE
Ultrasound Other (specify) _______________________
Pelvic Exam None
14. PREVIOUS PREGNANCIES (Complete each section)
LIVE BIRTHS OTHER TERMINATIONS
14a. Now Living
Number _______
None
14b. Now Dead
Number _______
None
14c. Spontaneous
(Include fetal deaths)
Number _______
None
14d. Induced (Do not
include this termination)
Number _______
None
15. TERMINATION PROCEDURES
15a. PROCEDURE THAT TERMINATED 15b. ADDITIONAL PROCEDURES
15a. PREGNANCY 15b. USED FOR THIS
15b. TERMINATION, IF ANY
15a. (Check only one) 15b. (Check all that apply)
(1) ................................................. Suction Curettage ............................................. (1)
(2) ..............................Medical (Nonsurgical) (Specify medications below) .......................... (2)
_________________________________________________________________
(3) ....................................... Dilation and Evacuation (D&E) ................................... (3)
(4) ......................... Intra-Uterine Instillation (Saline or Prostaglandin) ..................... (4)
(5) ............................................ Sharp Curettage (D&C) ......................................... (5)
(6) .......................................... Hysterotomy/Hysterectomy ...................................... (6)
(7) ...... Other (Specify) _______________________________________________ ... (7)
15c. COMPLICATIONS OF
15c. TERMINATION
15c. (Check all that apply)
(0) None
(1) Hemorrhage
(2) Infection
(3) Uterine Perforation
(4) Cervical Laceration
(5) Retained Products
(6) Other (Specify)
________________________
16. PATIENT EDUCATIONAL MATERIALS
16. PROVIDED?
YES NO
17. NAME OF ATTENDING PHYSICIAN
17. (Type/Print)
18. NAME OF PERSON COMPLETING REPORT
17. (Type/Print)
IF PATIENT IS UNDER 18 YEARS OF AGE, COMPLETE EITHER 19a. OR 19b.
IF DETERMINATION OF POSTFERTILIZATION AGE WAS 20 WEEKS OR GREATER, OR UNKNOWN, COMPLETE ITEM 20
19a. TERMINATION PERFORMED FOLLOWING PHYSICIAN’S RECEIPT OF: (Check only one)
19a. (1) Written informed consent of a parent, guardian or conservator and the minor
19a. (2) Written informed consent of emancipated minor for herself
19a. (3) Written informed consent of minor for herself pursuant to court order granting minor right to self-consent
19a. (4) Court order which includes finding that abortion is in best interests of minor, despite absence of parental consent
19a. (5) Certification from minor that pregnancy resulted from rape or sexual conduct with minor by the minor’s parent,
stepparent, uncle, grandparent, sibling, adoptive parent, legal guardian, or foster parent
OR
19b. TERMINATION PERFORMED FOLLOWING MEDICAL EMERGENCY: (Specify diagnosis below)
19b.1________________________________________________________________________________________________
20. MEDICAL CONDITION THAT NECESSITATED THE ABORTION AT 20 OR GREATER WEEKS POSTFERTILIZATION:
20. (1) Patient had a condition that so complicated her medical condition as to necessitate the abortion of this pregnancy
to avert her death or to avert serious risk of substantial and irreversible physical impairment of a major bodily
function, not including psychological or emotional conditions
20. (2) It was necessary to preserve the life of an unborn child
20. (3) Determination of probable postfertilization age was not made. Provide the basis of the determination that a medical
emergency existed: (specify below)
_________________________________________________________________________________________