Assessment for intrauterine contraception removal
Note: Questions marked by * are mandatory
Please ensure these contact details are correct. Unless your coil is being removed in order to become pregnant, it is really important that you aren’t at risk of conceiving by having your coil removed or are already pregnant if your coil is out of date.
* This is a mandatory field. If your coil is out of date, what other contraception have you been using?
* This is a mandatory field. Have you been using this method reliably for every episode of sex?
Please select an option
Yes No
* This is a mandatory field. Have you taken emergency contraception since your last period?
Please select an option
Yes No
* This is a mandatory field. Was this a normal period for you, at the expected time?
Please select an option
Yes No
* This is a mandatory field. Have you had a positive pregnancy test since your coil was fitted?
Please select an option
Yes No
* This is a mandatory field. Why do you want your coil removed?
Please select an option
To conceive It has expired Problems with it No partner at present Postmenopausal Other
* This is a mandatory field. Do you want another method of contraception?
Please select an option
Yes No
* This is a mandatory field. Have you felt the threads or have they been seen recently during a vaginal examination/smear?
Please select an option
Yes No
* This is a mandatory field. Was your coil insertion particularly painful or difficult?
Please select an option
Yes No
* This is a mandatory field. Are you experiencing abnormal vaginal bleeding? By this we mean: bleeding between periods, bleeding after sex or new and un-investigated bleeding that is heavier or irregular?
Please select an option
Yes No
* This is a mandatory field. Have you ever been diagnosed with fibroids
Please select an option
Yes No
If yes, have you had a pelvic scan to check your fibroids in the last 12-18 months?
Please select an option
Yes No
* This is a mandatory field. Have you had any surgery to your womb (excluding caesarean sections)?
Please select an option
Yes No
If yes, please give details:
* This is a mandatory field. Do you have children?
Please select an option
Yes No
If you answered yes, how old are your children and were any born by caesarean section?
* This is a mandatory field. Are you up to date with your cervical screening?
Please select an option
Yes No
* This is a mandatory field. Have you ever had an abnormal smear?
Please select an option
Yes No
If you answered yes, please give details of when this was and any treatment you had:
* This is a mandatory field. Do you have any other medical conditions?
Please select an option
Yes No
If yes, please give details:
* This is a mandatory field. Do you take any medication?
Please select an option
Yes No
If yes, please give details:
* This is a mandatory field. Are you allergic to anything?
Please select an option
Yes No
If yes, please give details:
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?
Please select an option
Yes No
* This is a mandatory field. Have you had more than one sexual partner in the last 12 months?
Please select an option
Yes No
* This is a mandatory field. Does your sexual partner have other sexual partners?
Please select an option
Yes No
* This is a mandatory field. Have you ever had any sexually transmitted infections?
Please select an option
Yes No
* This is a mandatory field. Have you been in contact with anyone who has had a sexually transmitted infection (STI)?
Please select an option
Yes No
* This is a mandatory field. Have you had any new vaginal discharge?
Please select an option
Yes No
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 and post as per the instructions. The results will be sent as a text to your mobile.
* This is a mandatory field. Is there any other information you would like to tell us that you think might be important or helpful? For example, did you faint or feel faint at your last coil fitting; 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?
Please select an option
Dartford Gravesham Maidstone Tunbridge Wells
* This is a mandatory field. Although we cannot guarantee a time to call you back, which would be your preferred time slot?
Please select an option
9am - midday Midday - 4pm I would prefer an email response
We will try to call you on two occasions – the number will be displayed as withheld.
