Free Republic

(TO BE COMPLETED FOR EACH ABORTION PERFORMED) 1. Date of abortion __ 2. County in which abortion performed 3. Age of mother _____ 4. Marital status of mother (married, divorced, separated, widowed, or never married) 5. Race of mother 6. Years of education of mother (specify highest year completed) 7. State or foreign country of residence of mother 8. Total number of previous pregnancies of the mother Live Births Miscarriages Induced Abortions 9. Approximate gestational age in weeks, as measured from the last menstrual period of the mother, of the unborn child subject to