The following questionnaire had been designed to help you identify symptoms in your life that may be related to a past abortion experience.

Select the symptoms that pertain to you.

• Sadness



• Feelings of loss



• Guilt



• Shame



• Regret



• Recurring thoughts about the abortion(s)



• Crying episodes



• Anxiety



• Fear of punishment from God



• Inability to sustain an intimate relationship



• Preoccupation with anniversaries, i.e., date of the abortion(s) or due date(s)



• Obsession with children or child-bearing



• Avoidance of small children and babies or pregnant women

• Difficulty bonding with other children



• Increased alcohol use



• Drug abuse



• Repeat abortions



• Multiple sexual relationships



• Engaging in any of the following to excess: school, work, exercise, eating, dieting



• Difficulty sleeping



• Feelings of numbness



• Lack of self-esteem



• Suicidal thoughts



• Desire for secrecy about the abortion



• Disinterest in sex

If you have selected symptoms from this list and would like to talk with a trained, non-judgmental counselor in a confidential environment, please call Care Net at 301-662-5300.

*Adapted from www.daybreakinc.org. Used by permission.