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Your Personal Information |
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First Name:
Last Name:
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Address:
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City:
State:
Zip/Postal Code:
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Country:
Phone Number:
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Email Address:
Date Of Birth:
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Ethnicity
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Hispanic or Latin |
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White |
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Black, African American |
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Asian |
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American Indian |
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Other Please Specify:
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Do you know anyone else personally who has had an
ectopic pregnancy?
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Have you suffered from or received treatment for
any of the following conditions prior to your 1st ectopic pregnancy?
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No |
Pelvic Infection |
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Mother |
Endometriosis |
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Daughter |
Had a Coil (IUD) |
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Sister |
Used the Mini Pill |
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Other Blood Relative |
Chlamydia |
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Other Relative |
Caesarean Section |
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Friend
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Appendicitis |
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Voluntary Termination |
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Fertility treatment, what type?
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Miscarriage |
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IUI (Intrauterine Insemination) |
Abdominal Surgery |
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IVF (Invitro Fertilization) |
Tubal Surgery |
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Fertility Treatment |
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D & C |
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Other Please Specify:
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Sterilization/Tubes Tied
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Pregnancies |
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Type of Pregnancy |
Total |
Number Before 1st Ectopic |
Number After 1st Ectopic |
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Live Births |
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Ectopics |
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Miscarriages |
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Still Births |
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Terminations |
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Please list your ectopic pregnancies in date order. |
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1st:
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2nd:
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3rd:
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4th:
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Your first Ectopic Pregnancy
experience. |
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If you had more than one ectopic pregnancy, please return to this page
after completing and submitting this form, scroll to the bottom and
click the link Additional Ectopic Pregnancies. It is important
to fill out the Additional Ectopic Pregnancy Questionnaire for each
ectopic. |
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Date of this ectopic pregnancy:
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What type of ectopic pregnancy did you have? (tubal, cornual,
etc.)
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Before your first ectopic pregnancy, did you know what an ectopic
pregnancy was?
Yes
No |
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What were your symptoms?
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Abdominal Pain |
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Vaginal Bleeding |
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Bowel Problems |
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Feeling Faint |
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Vomiting |
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Pain in the Shoulder |
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Feeling Unwell |
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Fainting |
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Late Period |
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To have scan because of a previous ectopic pregnancy |
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Scan following IVF or other infertility treatment |
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Sudden Collapse |
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None, Found during routine prenatal care |
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Please give details of any other symptoms you had: |
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By which healthcare professional were you first seen?
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Did you know or suspect you were pregnant?
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General Practitioner |
I knew I was pregnant |
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Midwife |
Suspected I was pregnant |
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RN |
I did not know I was pregnant
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Emergency Room Doctor |
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OB/Gyn |
Were you asked if you were pregnant?
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Emergency admission with collapse |
Yes |
No
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Don't know |
Was a pregnancy test done at this time? |
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Other Please Specify
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Yes |
No
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If you knew you were pregnant did you inform anyone? |
Did you suspect it was an ectopic pregnancy? |
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Yes
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No |
Yes
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No
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What color best describes the bleeding you had? |
Who first suspected it was an ectopic pregnancy? |
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Bright Red |
General Practitioner |
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Dark Red |
Midwife |
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Prune Juice |
OB/Gyn |
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Other Please Specify
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Emergency Room Doctor |
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None
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Other Please Specify
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What was your initial diagnosis? |
How many weeks pregnant were you? |
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Ectopic Pregnancy |
3
4
5
6
7
8
9 |
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Suspected Ectopic Pregnancy |
10
11
12
13
14
15
16 |
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Uterus Infection |
More than 16
Don't Know
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Gastro Problems |
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Food Poisoning |
How many weeks pregnant were you when your
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Appendicitis |
symptoms started to appear? |
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Irritable Bowel Syndrome |
3
4
5
6
7
8
9 |
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Possible Miscarriage |
10
11
12
13
14
15
16 |
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Ovarian Cysts |
More than 16
Don't Know
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Menstrual Disturbance |
What tests were performed? |
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Normal Pregnancy |
Urine Pregnancy Test |
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Treated for Miscarriage and Properly Diagnosed Later |
Single Blood Pregnancy Test |
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Other Please Specify
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Serial Blood Pregnancy Tests |
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Please state how many times you visited each of the |
Internal Exam |
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following before your ectopic pregnancy was |
Abdominal Ultrasound Scan |
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diagnosed. |
Vaginal (internal) Ultrasound Scan |
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General Practitioner:
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Other Please Specify
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OB/Gyn:
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None
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Hospital:
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After you Were Diagnosed as Having
an Ectopic Pregnancy |
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Was ectopic pregnancy fully explained to you after it was diagnosed? |
If you were given information, how was it given to you? |
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Yes
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No |
Verbally
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Written
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Were you given any options as to the treatment of your ectopic
pregnancy?
(Not all treatments are available in every hospital.)
(You may choose more than one.) |
What treatment did you actually receive for your Ectopic Pregnancy?
(Not all treatments are available in every hospital.)
(You may choose more than one.) |
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None |
Don't Know |
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Collapsed-Urgent Surgery Required |
Surgery |
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Surgery |
Keyhole |
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Keyhole |
Abdominal Incision |
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Abdominal Incision |
Removal of Tube |
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Removal of Tube |
Did not Remove Tube |
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Not Remove Tube |
Removed Uterus-Hysterectomy |
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Remove Uterus-Hysterectomy |
Removed Ovary |
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Remove Ovary |
Treated with Methotrexate-Had Surgery Later |
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Medical |
Medical |
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Methotrexate |
Methotrexate |
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Wait and See if it Would Resolve Itself
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Wait and See if it Would Resolve Itself
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Did your tube rupture? |
Did your uterus rupture? |
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Yes
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No
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Yes |
No
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Was your tube removed? |
Was part or all of your uterus removed? |
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No
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Partially Removed |
No
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Partially Removed
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Removed Completely
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Don't Know |
Removed Completely
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Don't Know
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Which tube was affected? |
Was part or all of your ovary removed? |
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Right
Left
Don't Know |
No
Partially Removed
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Removed Completely
Don't Know |
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Were you told what would happen to your baby? |
Which ovary was affected? |
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Yes
No |
Right
Left
Don't Know |
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Do you feel you were given an adequate explanation of the
treatment you received?
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What hospital were you treated at? Please give as much
information as you can; Name, Address, City, State, Zip, Phone
Number, etc. |
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Yes
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No |
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After Your Treatment |
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Were you informed of the risks of future ectopic pregnancies? |
Were you advised to have an early scan when you next became pregnant
to make sure your pregnancy was in the right place? |
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Yes |
No |
Yes |
No |
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Did the health professional who looked after you give you information
about local or national ectopic pregnancy support groups? |
Were you given any written information about ectopic pregnancies prior
to leaving the hospital? |
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Yes |
No |
Yes |
No |
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Were you given any information about the Ectopic Pregnancy Foundation? |
What information or literature were you given about the Ectopic
Pregnancy Foundation? |
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Yes |
No |
Website Address |
Brochure |
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Email |
Friend |
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Other Please Specify
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Pregnancies You Have Had After
This Ectopic |
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None |
Yes-I have conceived naturally. |
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My family is complete. |
Number of Children:
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Too scared to try again. |
Number of Miscarriages:
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Having difficulty conceiving. |
Number of Ectopics:
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Too soon after ectopic pregnancy. |
Yes-I have needed assisted conception (IVF, etc.) |
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Number of Children:
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Number of Miscarriages:
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Number of Ectopics:
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Have you suffered from any medical problems since having your
ectopic pregnancy that you did not have before and that you feel
could be associated with your ectopic pregnancy?
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Yes
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No |
If yes, please give details and treatment you received.
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Additional comments, or information not covered
during the questionnaire. |
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