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[Subsidiary]
CAP. 212] Termination of Pregnancy Regulations
7.
Previous pregnancies of woman-
(a) Number of live-births
[1982 Ed.
(b) Number of still births
(c) Number of pregnancies terminated
(d) If applicable, date of last termination of pregnancy under the Offences
against the Person Ordinance-
8.
Number of woman's existing children
9.
Date of admission to place of termination of pregnancy-
10.
Date of discharge from place of termination of pregnancy-
(Ring appropriate answer)
11.
12.
Was the terminated pregnancy that of a woman impregnated before attaining the age of 16 years?
Yes
No
If "Yes", give an estimate of her age at the time of impregnation.
Estimate
Was the terminated pregnancy that of a woman who had made a report to a police officer, that she had been the victim of an alleged offence under section 47 (which relates to incest), 118 (which relates to rape), 119 (which relates to intercourse procured by threats), 120 (which relates to intercourse procured by false pretences) or 127 (which relates to intercourse procured by drugs) of the Crimes Ordinance within a period not exceeding 3 months after the date upon which she alleged that any such offence was committed?
(Ring appropriate answer)
Yes
No
If "Yes", give the name of the alleged offence, the date that it was alleged to have been committed, the date and place of report to the police-
(a) Name of alleged offence
(b) Date of alleged offence
(c) Date of report to police
(d) Place of report to police
13.
Medical condition of woman-
(Ring appropriate letter)
(a) Obstetric disease (specify)
(b) Non-obstetric disease (specify)
14. Type of termination of pregnancy-
(a) Dilation and evacuation (b) Hysterotomy-abdominal
(c) Hysterotomy-vaginal
(d) Hysterectomy-abdominal
(e) Hysterectomy-vaginal
(f) Vacuum aspiration
(g) Other (specify)
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