Assessment form for intrauterine contraception exchange

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Assessment form for intrauterine contraception exchange

Intra uterine contraception (IUC) is very safe and very effective.

The 52mg LNG-IUD (Mirena/Levosert/Benilexa) also reduces heavy menstrual blood flow and can be used as a component of HRT (hormone replacement therapy).

So we can offer the best and safest service and ensure our appointments are used optimally, please fill in the form below.

Once you have returned the form, we will will be in touch within 14 days to book your IUC exchange appointment. Please email mtw-tr.coilassessmentdoc@nhs.net if you don’t hear anything within 14 days of submitting your form.

If you want a coil exchange and your coil is in date, please abstain from sex or use condoms reliably for seven days before your procedure.

If you want a coil exchange and your coil is out of date, please abstain from sex or use condoms reliably for 21 days before your procedure.

Assessment form for intrauterine contraception exchange

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. Phone number

*This is a mandatory field. Email address

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

*This is a mandatory field. When was your coil fitted?

*This is a mandatory field. What is the name of your coil?

*This is a mandatory field. If your coil exchange is overdue, what other contraception have you been using?

*This is a mandatory field. Have you felt the threads or have they been seen recently during a vaginal examination/smear?

*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. Have you taken emergency contraception since your last period?

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 more than one sexual partner in the last 12 months?

*This is a mandatory field. Does your sexual partner have other sexual partners?

*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 and post it as per the instructions. The results will be sent in a text to your mobile.

*This is a mandatory field. Are you experiencing abnormal vaginal bleeding? By that we mean bleeding between periods, bleeding after sex or new and un-investigated bleeding that is heavier or irregular?

*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 the answer to the last question was yes, how old are they and were any born by caesarean section?

*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 you had:

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

If yes, please give details

*This is a mandatory field. Do you take any medication?

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 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 fit; was a general anaesthetic needed; 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?

*This is a mandatory field. Although we cannot guarantee a time to call you back, which would be your preferred time slot?

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

Important information

If you want a coil exchange and your coil is in date, please abstain from sex or use condoms reliably for seven days before your procedure.

If you want a coil exchange and your coil is out of date, please abstain from sex or use condoms reliably for 21 days before the procedure.

Please be prepared to provide a urine specimen on the day, before your procedure.
We can fit a coil if you are having your period on the day of the appointment
Please ensure you have eaten and been drinking normally before your appointment.
You may wish to take some painkillers one hour before your appointment.
It is a good idea to bring a sanitary towel or pantyliner to your appointment in case of any bleeding afterwards.
You can change your mind about which coil you decide to have fitted on the day.
You may bring someone to accompany you to wait in the waiting room during your appointment.

If there is any risk of pregnancy, it may not be possible to fit the coil.

So, please either abstain from sex or use a reliable method of contraception correctly for at least 21 days before the procedure (reliable methods of contraception do not include withdrawal or fertility awareness methods/apps).

Assessment form for intrauterine contraception exchange

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Assessment form for intrauterine contraception exchange

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