Medication Abortion

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Welcome to Choix! This 5 minute questionnaire is only intended for pregnant patients seeking pregnancy termination services using medications that will be mailed to your home. If you are the partner of a pregnant patient, please have them fill out this form themselves--and thanks for your support! We can only discuss our patients healthcare with them directly.
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What you will need...

Date of your last period (ie the start of)

Date of positive pregnancy test

Payment info ($20 consult fee)

Photo ID and a clear selfie for purposes of identification

*If you do not know the date of your last period, that’s okay--still fill out the form. If you have not taken a pregnancy test, please complete one prior to filling out this form.
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Do you agree to our telehealth consent and terms and conditions? * This field is required.Please note that you will need to submit this form in order for a provider to review it. If you just curious about the questions, then you do not need to submit the form.
AgreeDisagree
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In order to use Choix, you do need to agree to our legal terms. If you want to review them then head over to our legal section or if you have any questions, please send us a note at support@mychoix.co.
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PROFILEID
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By clicking yes below, I confirm that I am providing my own medical information and I will be the person taking the medication.* This field is required.
YESNO
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Thank you for your interest in Choix. As mentioned, the person who will be receiving these medications is who is to be filling out this questionnaire and providing their medical history.

Please have them visit our site and submit a questionnaire.
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What is your age?
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In which state do you plan to receive your medical care? Each telehealth visit must take place within the state you select.* This field is required.Choix only operates in a limited number of states.
California
Colorado
Illinois
Maine
New Mexico
10
Were you assigned the female gender at birth?
YESNO
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Choix can only provide medical abortion service for patients that were assigned the female gender at birth, and seeking medical care within the following states and age groups.

- California, Illinois and New Mexico (15 years old or older)

- Colorado (15 years old or older with parental notification)

This unfortunately means that we will not be able to meet your needs at this time. Please follow up with your health care provider or visit Bedsider's Clinic Finder for additional care.
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I know the date of my last menstrual cycle?* This field is required.
YESNO
13
What is the first day of your last menstrual period (LMP)?This is the day you started spotting or bleeding and had a normal period. It is not when your period ended.
Date
Month
Day
Year
14
Do you know approximately the date of your last menstrual period?* This field is required.Approximate is within a week of a specific date ie it was sometime the week of June 30th.
YESNO
15
Since you know the approximate date of your last menstrual period, please select it below.* This field is required.Select a date within a week of your last known menstrual period ie 6/30/2022.
Date
Month
Day
Year
16
What is the date of your first positive home pregnancy test?* This field is required.
Date
Month
Day
Year
17
Please list any health conditions you have. * This field is required.Asthma, diabetes, chronic migraines, etc...
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Do you have any allergies to any medications?* This field is required.If not, please enter No.
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Please list any medications that you are taking.* This field is required.Prescription and/or over the counter
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Have you ever been diagnosed with anemia or iron deficiency so severe you required a blood transfusion?* This field is required.
YESNO
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Look at that. You are halfway done with this questionnaire. 🙂
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Have you ever been diagnosed with anemia AND been symptomatic for that condition at the time of diagnosis? Symptoms of anemia may include: Fatigue, shortness of breath, dizziness, pale color of eyelids/lips/tongue/skin, headache, or heart palpitations.* This field is required.
YESNO
23
Have you ever had excessive bleeding/hemorrhage following a medical procedure that required a blood transfusion?* This field is required.
YESNO
24
Have you ever had an ectopic pregnancy?* This field is required.An ectopic pregnancy, also called extrauterine pregnancy, is when a fertilized egg grows outside a woman's uterus, somewhere else in her belly.
YESNO
25
How was your ectopic pregnancy managed?
Huge
Large
Normal
Small
Ok
Ok
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If you have been pregnant, have you ever had a hemorrhage (excessive bleeding) after delivery/miscarriage/abortion that required a blood transfusion?* This field is required.Answer Not applicable if you have never been pregnant.
Yes
No
Not applicable
27
Please check off any of the following medical conditions or situations that apply to you.* This field is required.You may need to scroll to see all 9 options.
Allergy to prostaglandins or mifepristone
Chronic adrenal failure
Long-term use of systemic corticosteroids (for example, you take a pill daily or get regular steroid injections for a medical condition)
Hemorrhagic (bleeding) disorder
Inherited porphyria
Currently using anticoagulant therapy
Allergy to ondansetron (Zofran) or ibuprofen
IUD in place
None of the above
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Please check off any of the following that apply to you* This field is required.You may need to scroll to see all 6 options.
I have had bleeding since my last menstrual period (even spotting)
History of tubal surgery
History of treatment for Pelvic Inflammatory Disease (PID)
I have had pain or tenderness in my ovaries, particularly on one side
IUD in place
None of the above
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Are your periods Regular or Irregular?* This field is required.Regular periods come around the same time every month (but maybe not the exact same day) or you have the same number of weeks between periods, and do NOT go more than 6 weeks without a period. If your period ever skips a month, or you sometimes get 2 periods in a month, this would be considered irregular.
Regular
Irregular
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How are your periods irregular?* This field is required.Select all that apply.
They never come around the same time each month
I consistently go more than 5 weeks without a period
I sometimes skip one month or more without a period
Irregular in some other way
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Have you had an ultrasound done in this pregnancy?* This field is required.
YESNO
32
What date was your ultrasound performed?
Date
Month
Day
Year
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How far along were you in the pregnancy on the day your ultrasound was performed?Please write your answer in week/day format, for example 7 weeks 3 days.
34
5 questions left! Almost there. 😎
35
Were you using birth control in the 3 months prior to becoming pregnant? If so, what method and what date did you stop taking it?* This field is required.If you were not using birth control in the 3 months prior, please answer No.
36
Have you ever been pregnant before (not including this pregnancy)?* This field is required.
YESNO
37
What was the outcome of your past pregnancies (not including this pregnancy)?Please list a number 0, 1 or greater next to the pregnancy outcomes listed. Enter text in "Other" if there is an outcome not captured.
Abortions
Miscarriages
Stillbirths
Live births
Currently living children
Other
38
The following are questions that will asses your safety and preparedness for having an abortion at home. Please check off all of the following as they apply to you.* This field is required.You may need to scroll to see all 5 options.
I have reliable access to a telephone
I have access to an emergency room that is within a 1 hour drive
I have someone at home/near by to help me in case of an emergency
I have someone supporting my decision to have an abortion
None of the above
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Given the previous information, check off the below option that applies to you.* This field is required.You may need to scroll to see all 5 options.
I know my blood type is positive (A positive, B positive, AB positive or O positive. This is also sometimes written A+, B+, AB+, or O+)
I know my blood type is negative (A negative, B negative, AB negative or O negative. This is also sometimes written A-, B-, AB-, or O-), and I accept the risks, I do not want to Rh immune globulin.
I know my blood type is negative (A negative, B negative, AB negative or O negative. This is also sometimes written A-, B-, AB-, or O-), and I do want the Rh immune globulin *Please note, this selection will require you to visit your local clinic or hospital to receive the injection.
I do not know my blood type, and do not want to get tested. I accept the risks associated with this medication abortion and have been counseled appropriately.
I do not know my blood type, and I would like to get tested. **Please note, if you select this option, we will gladly order your blood type to be tested/drawn at a lab, or direct you to purchase a home Rh test kit. This may delay your ability to receive medications. If you are Rh-negative, you will have to visit a clinic or hospital for the injection**
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EmailWe use your email to create your patient account in our portal and general notifications. It will not be used for any healthcare related communication.
someone@example.com
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What is your preferred method of communication?* This field is required.
Text message (Just like phone calls and voicemails, texting may not always be 100% secure depending on the mobile service you use.)
Encrypted Text Message (We will send all texts as encrypted messages that require a login, password and is separate from your Choix login.)
42
In the event we need to contact you by phone is it okay to identify ourselves by phone or when we leave a message?* This field is required.If you select NO, we will leave a voicemail using the code name “Charlotte”.
YESNO
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Anything else you want our providers to know?Pregnancy, abortion, or medical history that our medical providers should be aware of (previous problems with medication abortion, recent failed medication abortion, or any other health history)?
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That's it for the questions. :-)

Next steps, are just payment and a portal account. Our medical providers will review your medical history (within 24 hours of receipt, Monday through Friday between 9 am and 5 pm) to determine if you are eligible for a medication abortion via telehealth with Choix.

While the vast majority of patients do not require an ultrasound, our providers MAY require an ultrasound or lab work before we are able to proceed with your care from Choix. This is solely based upon your medical history.

Our initial consultation fee is $20 and if you are eligible for care, we will apply this $20 towards the total cost.

Please do not submit multiple questionnaires as our providers need to review all information you submitted. You will not be refunded for duplicate orders. If there is something you need to change about your submission, or you have questions about your order, please email support@mychoix.co.
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