Smoke
Done here.
(continued)
REASON GIVEN FOR ABORTION (check all applicable):
Having a baby:
Would dramatically change the life of the mother: _________
Would interfere with the education of the mother: _________
Would interfere with the job/employment/career of the mother: ______
Mother has other children or dependents: ________
Mother cannot afford the child: ______
Mother is unmarried: ________
Mother is a student or planning to be a student: ________
Mother cannot afford child care: _______
Mother cannot afford the basic needs of life: ________
Mother is unemployed: _________
Mother cannot leave job to care for a baby: _________
Mother would have to find a new place to live: _________
Mother does not have enough support from a husband or partner: _____
Husband or partner is unemployed: _______
Mother is currently or temporarily on welfare or public assistance: _________
Mother does not want to be a single mother: _______
Mother is having relationship problems: ________
Mother is not certain of relationship with the father of the child: ________
Partner and mother are unable to or do not want to get married: _______
Mother is not currently in a relationship: _______
The relationship or marriage of the mother may soon break up: _______
Husband or partner is abusive to the mother or her children: _______
Mother has completed her childbearing: ________
Mother is not ready for a, or another, child: _______
Mother does not want people to know that she had sex or became pregnant: ________
Mother does not feel mature enough to raise a, or another, child: _______
Husband or partner wants mother to have an abortion: ______
There may be possible problem affecting the health of the fetus: ________
Physical health of the mother is at risk: ________
Parents want mother to have an abortion: _________
Emotional health of the mother is at risk: ________
Mother suffered from a medical emergency as defined in Section 1-738.1 of Title 63 of the Oklahoma Statutes: ______
Mother wanted a child of a different sex: ______
Abortion is necessary to avert the death of the mother: ______
Pregnancy was a result of forcible rape: ______
Pregnancy was a result of incest: ______
Other (specify): ______
Patient was asked why she is seeking an abortion, but she declined to give a reason: _______
16. Method of payment (check one):
Private insurance: _______
Public health plan: _______
Medicaid: _______
Private pay: _______
Other (specify): _____________________________
17. Type of private medical health insurance coverage, if any (check one):
Fee-for-service insurance company: ______
Managed care company: ______
Other (specify): _____________________________
18. Sum of fee(s) collected: ___________
19. Time of fee collection (check one):
Full fee for abortion collected prior to or at the time the patient was provided the information required under subsection A of Section 1-738.2 of Title 63 of the Oklahoma Statutes: _________
Partial fee for abortion collected prior to or at the time the patient was provided the information required under subsection A of Section 1-738.2 of Title 63 of the Oklahoma Statutes: _________
Full fee for abortion collected at time the abortion was performed: ________
Other (specify): ________
20. Specialty area of medicine of the physician: _________________
______________________________________________________________
21. Was ultrasound equipment used before, during, or after the performance of this abortion?
Before? _____ Vaginal, abdominal, or both? _____
During? _____ Vaginal, abdominal, or both? _____
After? _____ Vaginal, abdominal, or both? _____
22. If ultrasound equipment was used, was the ultrasound performed by:
The physician performing the abortion: _____
A physician other than the physician performing the abortion: _____
Other (specify): ___________________________
23. Was the information required by paragraph 1 of subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes provided to the mother? ___________
a. If yes, was it provided:
In person: ___________
By telephone: ___________
b. Was it provided by:
A referring physician: __________
The physician performing the abortion: _________
An agent of a referring physician: ___________
An agent of the physician performing the abortion: ________
24. Was the information required by paragraph 2 of subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes provided to the mother? _________
a. If yes, was it provided:
In person: _______
By telephone: _______
b. Was it provided by:
A referring physician: _______
An agent of a referring physician: _______
The physician performing the abortion: ________
An agent of the physician performing the abortion: _______
25. Did the mother avail herself of the opportunity to have the printed materials described in Section 1-738.3 of Title 63 of the Oklahoma Statutes mailed to her? ______________
26. Were the informed consent requirements of subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes dispensed with because of a medical emergency necessitating an immediate abortion:
To avert death: ______
To avert substantial and irreversible impairment of a major bodily function arising from continued pregnancy: _____
27. Was the probable gestational age of the unborn child twenty (20) weeks or more? _____
a. If yes, was the mother provided the information described in subsection A of Section 1-738.8 of Title 63 of the Oklahoma Statutes? _____
(1) If yes, was the information provided:
In person: ______
By telephone: ______
(2) If yes, was the information provided by:
A referring physician: _____
An agent of a referring physician: _____
The physician performing the abortion: _____
An agent of the physician performing the abortion: _____
b. Did the mother choose to be given or mailed the materials described in Section 1-738.10 of Title 63 of the Oklahoma Statutes? ___________
c. To the best of the information and belief of the reporting physician, did the mother go on to obtain the abortion? ________
28. Was the abortion performed within the scope of employment of an Oklahoma state employee or an employee of an agency or political subdivision of the state? ________
29. Was the abortion performed with the use of any public institution, public facility, public equipment, or other physical asset owned, leased, or controlled by this state, its agencies, or political subdivisions? _________
30. If the answer to question 28 or 29 is yes:
a. Was the abortion necessary to save the life of the mother? _______
If yes, what was the life-endangering condition? __________
b. Did the pregnancy result from an act of forcible rape? _______
If yes, list the law enforcement authority to which the rape was reported: ___________________
List the date of the report: ___________
c. Did the pregnancy result from an act of incest committed against a minor? _________
If yes, list the law enforcement authority to which the perpetrator was reported: ________________
List the date of the report: ___________
THIS PORTION TO BE COMPLETED IN CASE OF MINOR
31. Minors age at the time the abortion was performed: ___________
32. Was a parent of the minor provided notice prior to the abortion as described in Section 1-740.2 of Title 63 of the Oklahoma Statutes? ________
a. If yes, how was the notice provided?
In person: _______
By mail: _______
b. If yes, to the best of the reporting physicians knowledge and belief, did the minor go on to obtain the abortion? ________
33. Was informed written consent of one parent obtained as described in Section 1-740.2 of Title 63 of the Oklahoma Statutes? ______
If yes, how was it secured?
In person: ___________
Other (specify): _________
34. If no notice was provided nor consent obtained, indicate which of the following apply:
Minor was emancipated: ___________
Abortion was necessary to prevent the death of the minor: _____
Medical emergency, as defined in Section 1-738.1 of Title 63 of the Oklahoma Statutes, existed: ___________
Minor received judicial authorization to obtain abortion without parental notice or consent: ___________
35. If no notice was provided nor consent obtained because a medical emergency existed, indicate:
Whether parent was subsequently notified (state period of time elapsed before notice was given): ____________
Whether judicial waiver of notice requirement was obtained: ________
36. If the minor received judicial authorization to obtain an abortion without parental notice or consent, indicate which of the following applies:
Judge ruled that minor was mature enough to give informed consent on her own: ___________
Judge ruled that abortion was in the best interest of the minor: ___________
37. If the female was a minor at the time of conception, indicate the age of the father of the unborn child at the time of conception: ________
38. If at the time of conception the ages of the mother and father were such that a violation of Section 1111, 1112, 1114 or 1123 of Title 21 or Section 7115 of Title 10 of the Oklahoma Statutes occurred, was the rape or abuse reported to the proper authorities? ________
Filed this ____ day of __________, _____, by:
______________________________
(Name of physician)
_____________________________
(Physicians license number)
REASON GIVEN FOR ABORTION (check all applicable):
Having a baby:
Would dramatically change the life of the mother: _________
Would interfere with the education of the mother: _________
Would interfere with the job/employment/career of the mother: ______
Mother has other children or dependents: ________
Mother cannot afford the child: ______
Mother is unmarried: ________
Mother is a student or planning to be a student: ________
Mother cannot afford child care: _______
Mother cannot afford the basic needs of life: ________
Mother is unemployed: _________
Mother cannot leave job to care for a baby: _________
Mother would have to find a new place to live: _________
Mother does not have enough support from a husband or partner: _____
Husband or partner is unemployed: _______
Mother is currently or temporarily on welfare or public assistance: _________
Mother does not want to be a single mother: _______
Mother is having relationship problems: ________
Mother is not certain of relationship with the father of the child: ________
Partner and mother are unable to or do not want to get married: _______
Mother is not currently in a relationship: _______
The relationship or marriage of the mother may soon break up: _______
Husband or partner is abusive to the mother or her children: _______
Mother has completed her childbearing: ________
Mother is not ready for a, or another, child: _______
Mother does not want people to know that she had sex or became pregnant: ________
Mother does not feel mature enough to raise a, or another, child: _______
Husband or partner wants mother to have an abortion: ______
There may be possible problem affecting the health of the fetus: ________
Physical health of the mother is at risk: ________
Parents want mother to have an abortion: _________
Emotional health of the mother is at risk: ________
Mother suffered from a medical emergency as defined in Section 1-738.1 of Title 63 of the Oklahoma Statutes: ______
Mother wanted a child of a different sex: ______
Abortion is necessary to avert the death of the mother: ______
Pregnancy was a result of forcible rape: ______
Pregnancy was a result of incest: ______
Other (specify): ______
Patient was asked why she is seeking an abortion, but she declined to give a reason: _______
16. Method of payment (check one):
Private insurance: _______
Public health plan: _______
Medicaid: _______
Private pay: _______
Other (specify): _____________________________
17. Type of private medical health insurance coverage, if any (check one):
Fee-for-service insurance company: ______
Managed care company: ______
Other (specify): _____________________________
18. Sum of fee(s) collected: ___________
19. Time of fee collection (check one):
Full fee for abortion collected prior to or at the time the patient was provided the information required under subsection A of Section 1-738.2 of Title 63 of the Oklahoma Statutes: _________
Partial fee for abortion collected prior to or at the time the patient was provided the information required under subsection A of Section 1-738.2 of Title 63 of the Oklahoma Statutes: _________
Full fee for abortion collected at time the abortion was performed: ________
Other (specify): ________
20. Specialty area of medicine of the physician: _________________
______________________________________________________________
21. Was ultrasound equipment used before, during, or after the performance of this abortion?
Before? _____ Vaginal, abdominal, or both? _____
During? _____ Vaginal, abdominal, or both? _____
After? _____ Vaginal, abdominal, or both? _____
22. If ultrasound equipment was used, was the ultrasound performed by:
The physician performing the abortion: _____
A physician other than the physician performing the abortion: _____
Other (specify): ___________________________
23. Was the information required by paragraph 1 of subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes provided to the mother? ___________
a. If yes, was it provided:
In person: ___________
By telephone: ___________
b. Was it provided by:
A referring physician: __________
The physician performing the abortion: _________
An agent of a referring physician: ___________
An agent of the physician performing the abortion: ________
24. Was the information required by paragraph 2 of subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes provided to the mother? _________
a. If yes, was it provided:
In person: _______
By telephone: _______
b. Was it provided by:
A referring physician: _______
An agent of a referring physician: _______
The physician performing the abortion: ________
An agent of the physician performing the abortion: _______
25. Did the mother avail herself of the opportunity to have the printed materials described in Section 1-738.3 of Title 63 of the Oklahoma Statutes mailed to her? ______________
26. Were the informed consent requirements of subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes dispensed with because of a medical emergency necessitating an immediate abortion:
To avert death: ______
To avert substantial and irreversible impairment of a major bodily function arising from continued pregnancy: _____
27. Was the probable gestational age of the unborn child twenty (20) weeks or more? _____
a. If yes, was the mother provided the information described in subsection A of Section 1-738.8 of Title 63 of the Oklahoma Statutes? _____
(1) If yes, was the information provided:
In person: ______
By telephone: ______
(2) If yes, was the information provided by:
A referring physician: _____
An agent of a referring physician: _____
The physician performing the abortion: _____
An agent of the physician performing the abortion: _____
b. Did the mother choose to be given or mailed the materials described in Section 1-738.10 of Title 63 of the Oklahoma Statutes? ___________
c. To the best of the information and belief of the reporting physician, did the mother go on to obtain the abortion? ________
28. Was the abortion performed within the scope of employment of an Oklahoma state employee or an employee of an agency or political subdivision of the state? ________
29. Was the abortion performed with the use of any public institution, public facility, public equipment, or other physical asset owned, leased, or controlled by this state, its agencies, or political subdivisions? _________
30. If the answer to question 28 or 29 is yes:
a. Was the abortion necessary to save the life of the mother? _______
If yes, what was the life-endangering condition? __________
b. Did the pregnancy result from an act of forcible rape? _______
If yes, list the law enforcement authority to which the rape was reported: ___________________
List the date of the report: ___________
c. Did the pregnancy result from an act of incest committed against a minor? _________
If yes, list the law enforcement authority to which the perpetrator was reported: ________________
List the date of the report: ___________
THIS PORTION TO BE COMPLETED IN CASE OF MINOR
31. Minors age at the time the abortion was performed: ___________
32. Was a parent of the minor provided notice prior to the abortion as described in Section 1-740.2 of Title 63 of the Oklahoma Statutes? ________
a. If yes, how was the notice provided?
In person: _______
By mail: _______
b. If yes, to the best of the reporting physicians knowledge and belief, did the minor go on to obtain the abortion? ________
33. Was informed written consent of one parent obtained as described in Section 1-740.2 of Title 63 of the Oklahoma Statutes? ______
If yes, how was it secured?
In person: ___________
Other (specify): _________
34. If no notice was provided nor consent obtained, indicate which of the following apply:
Minor was emancipated: ___________
Abortion was necessary to prevent the death of the minor: _____
Medical emergency, as defined in Section 1-738.1 of Title 63 of the Oklahoma Statutes, existed: ___________
Minor received judicial authorization to obtain abortion without parental notice or consent: ___________
35. If no notice was provided nor consent obtained because a medical emergency existed, indicate:
Whether parent was subsequently notified (state period of time elapsed before notice was given): ____________
Whether judicial waiver of notice requirement was obtained: ________
36. If the minor received judicial authorization to obtain an abortion without parental notice or consent, indicate which of the following applies:
Judge ruled that minor was mature enough to give informed consent on her own: ___________
Judge ruled that abortion was in the best interest of the minor: ___________
37. If the female was a minor at the time of conception, indicate the age of the father of the unborn child at the time of conception: ________
38. If at the time of conception the ages of the mother and father were such that a violation of Section 1111, 1112, 1114 or 1123 of Title 21 or Section 7115 of Title 10 of the Oklahoma Statutes occurred, was the rape or abuse reported to the proper authorities? ________
Filed this ____ day of __________, _____, by:
______________________________
(Name of physician)
_____________________________
(Physicians license number)
