9505020091087

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Profile Profile

Gynae and Obstetric History Gynae and Obstetric History

Screening Tool Screening Tool

Family Planning Family Planning

Risks associated Risks associated

Notes Notes

Annexure A Annexure A

Request Consent Request Consent

Client Consent Client Consent

TTOs / Drug Chart TTOs / Drug Chart

Follow Up Visit Follow Up Visit

Safe Abortion Safe Abortion

Print Profile Print Profile

First Name

Monique

Last Name

Connor

Birth Date

2 May 1995

Centre Name

Marie Stopes clinic Cape Town

Contact Number

0795002143

Consultation Date

28 Dec 2023

Time

11:45

Occupation

Scrum Master

Cellphone

0795002143

Emergency Person

Ryall Connor - 0848717119

Relationship to contact

Husband

Street Name & Number

10 Trent Road

Suburb

Cape Town

City

Cape Town

Postal Code

7800

Did someone refer/recommend you to Marie Stopes for your visit today?

10. I was not referred

Did you hear about Marie Stopes via any media in the last 3 months?

3. Social media (ie. Facebook, Twitter)

Why did you choose Marie Stopes for your visit today?

I like their approach to pro choice and feel comfortable that their best interests are the same as mine.

Would you like to receive further information about Marie Stopes and our services via email?

Demographic Information - Education

Degree/diploma

Demographic Information - Race

White

Demographic Information - Employment

Employed

Reason for visit

Safe abortion care

Medical and Surgical History

Headaches/ Migraines

What was the first day of your last normal monthly period (LNMP)?

22 Nov 2023

Did you take medication today?

Do you have any allergies to medication?

Have you been admitted to hospital for any reason or for an operation?

Yes

If yes, please specify date(s) of admission

28 March 2022

Reason(s) for hospitalisation

c-scection birth

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