Assessment for intrauterine contraception insertion

Coil insertion

Note: Questions marked by * are mandatory

*This is a mandatory field. Full name

*This is a mandatory field. Date of birth

*This is a mandatory field. Age

*This is a mandatory field. Country of birth

*This is a mandatory field. Ethnic group

*This is a mandatory field. Phone number

*This is a mandatory field. Email address

*This is a mandatory field. Address line 1

Address line 2

*This is a mandatory field. Town/city

*This is a mandatory field. County

*This is a mandatory field. Post code

Please ensure these contact details are correct. It is also really important you are not pregnant at the time of IUC fitting.

*This is a mandatory field. Have you used IUC before?

*This is a mandatory field. If you answered 'yes' what was name of your coil and how long ago was it removed?

*This is a mandatory field. What sort of coil would you like fitted?

*This is a mandatory field. What was the first day of your last period?

*This is a mandatory field. Was this a normal period for you, at the expected time?

*This is a mandatory field. What is your current contraceptive method?

*This is a mandatory field. If you answered "other" please specify

*This is a mandatory field. Have you taken emergency contraception in the last few weeks?

If required, please continue using your contraception reliably until your IUC is fitted. For your safety, we must ask some sensitive questions to assess the risks of sexually transmitted infections:

*This is a mandatory field. How long have you been together with your current sexual partner?

*This is a mandatory field. Have you had a new sexual partner in the last 12 months?

*This is a mandatory field. Have you had more than one sexual partner in the last 12 months?

*This is a mandatory field. Have you ever had any sexually transmitted infections?

*This is a mandatory field. Have you been in contact with anyone who has had a sexually transmitted infection (STI)

*This is a mandatory field. Have you had any new vaginal discharge?

If the answers to any of the infection questions are YES, please visit SH.UK and register to receive an STI screening kit. You can do the STI screen in the comfort of your own home. Once complete please post as per the instructions. The results will be sent as a text to your mobile phone.

*This is a mandatory field. Are your periods very heavy or lasting longer than 7 days

If yes, has this been investigated with an ultrasound scan or gynaecology referral?

If this has been investigated, please provide details

*This is a mandatory field. Do you have any bleeding other than your period, e.g. after sex or in between periods?

If yes, has this been investigated with an ultrasound scan, swabs or gynaecology referral?

If this has been investigated please give details

*This is a mandatory field. Have you ever been diagnosed with fibroids?

If yes, have you had a pelvic scan to check your fibroids in the last 12-18 months?

*This is a mandatory field. Have you had any surgery to your womb (excluding caesarean sections)?

If yes, please give details

*This is a mandatory field. Has anyone ever tried to fit or remove a coil for you and failed or found it very difficult?

*This is a mandatory field. Do you have children?

If yes, please give details

*This is a mandatory field. Have you had a termination of pregnancy (abortion) in the last 3 weeks?

*This is a mandatory field. Are you up to date with your cervical screening?

*This is a mandatory field. Have you ever had an abnormal smear?

If yes, please give details of when this was and any treatment received

*This is a mandatory field. Do you have any other medical conditions?

If yes, please give details

*This is a mandatory field. Are you allergic to anything?

If yes, please give details

*This is a mandatory field. Is there any other information that you think might be important or helpful? For example, did you faint or feel faint at your last coil fit; was a general anaesthetic required; do you have any specific pain relief requests; is it for HRT or non-contraceptive use?

*This is a mandatory field. What would be your preferred clinic?

Although we cannot guarantee a time to call you back, which would be your preferred time slot?

We will try to call you on two occasions – the number will be displayed as withheld.

If we are unable to contact you by phone, we will send a text or leave a voice message inviting you to call in to make an appointment. If you do not want us to leave a voice message or send a text, please check the box.

I do not want you to leave a voicemail or send a text

Assessment for intrauterine contraception insertion

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