CANADA SILENT NO MORE TESTIMONIES: Are you hurting after an abortion(s) or regret it? Have you since developed infertility, depression, breast or cervical cancer, eating disorders, anxiety, substance abuse, suicidal thoughts, self destructive behaviour, unresolved grief, remorse, unworthiness, low self-esteem, abusive relationships, promiscuity or loss of interest in sex, anger, infection, haemorrhaging, damaged cervix, scarred/damaged uterus, miscarriages, premature births, flashbacks, shame, guilt, fear, inability to forgive yourself…? We may use part or all of your testimony to share your pain of abortion. Please let us know if we can use your full name, first name only, or initials. Please sign, date and return the form to CSNM 107 Discovery Ave. Morinville, AB. T8R 1N1 Thank you so much. 1. How old are you now? __________ How old were you when you had your first abortion? __________2nd ________ 3rd _______4th _____ 2. Did you feel pressured by anyone? _________if so who? __________________________________ 3. Approximately when and where did your abortion(s) occur?________________ _________________________________________________________________________________ 4. Aprox. how far along were you? ______________________________________________________ 5. Were you adequately informed of the nature and consequences of abortion, what it really is and does? ___________________________________________________________________________ 6. Were you informed by doctor or staff of the link between abortion and breast or cervical cancer? Yes/No ____________________________________________ 7. Have you had any lumps/cysts in your breasts?___________________________________________ 8. How has your abortion affected your life?_______________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 9. Have you sought medical, professional or counselling help? _________________________________ 10. How has your abortion(s) affected others in your life? ____________________________________ ____________________________________________________________________________________ 11. Based on your own experience, what would you tell a woman considering an abortion today? _________________________________________________________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________ 12. Are you willing to be silent no more and share your pain of abortion with us. You may also send a story form on a separate page. _____________________________ ________________________________ Print Name Address/email Phone number ____________________ _______________________________ _______________________ Signature Date Please use my initials only □ You may use my full name □ |
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