Assessment form for intrauterine contraception exchange - Maidstone and Tunbridge Wells NHS Trust

Coil exchange

Intra Uterine Contraception (IUC) is very safe and very effective contraception. The IUS (Mirena) also reduces heavy menstrual blood flow and can be used as a component of HRT (hormone replacement therapy). In order that we offer the best and safest service and to ensure our appointments are used optimally, please fill in the questionnaire below. Email completed form to: mtw-tr.coilassessmentdoc@nhs.net Once you have returned the form, one of our staff will be in touch within 14 days to book your IUC exchange appointment. Please contact us via the email above if you don’t hear anything within 14 days of submitting your form.

Full name(Required)

Date of birth(Required)

Age(Required)

Phone number(Required)

Email address(Required)

Please ensure these contact details are correct. Also be advised that it is really important that you are not pregnant at the time of IUC fitting.

When was your coil fitted?(Required)

What is the name of your coil?(Required)

If your coil exchange is overdue, what other contraception have you been using?(Required)

Have you felt the threads or have they been seen recently during a vaginal examination/smear?(Required)

What was the first day of your last period?(Required)

Was this a normal period for you, at the expected time?(Required)

Have you taken EMERGENCY CONTRACEPTION since your last period?(Required)

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:

How long have you been together with your current sexual partner?(Required)

Have you had more than one sexual partner in the last 12 months?(Required)

Does your sexual partner have other sexual partners?(Required)

Have you ever had any sexually transmitted infections?

Have you been in contact with anyone who has had a sexually transmitted infection (STI)?(Required)

Have you had any new vaginal discharge?(Required)

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

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?(Required)

Have you ever been diagnosed with fibroids or had any surgery to your womb?(Required)

Has anyone ever tried to fit or remove a coil for you and failed or found it very difficult?(Required)

Do you have children?(Required)

If the answer to the last question is yes, how old are they and were any born by Caesarean Section?

Have you had a Termination of Pregnancy (abortion) in the last 3 weeks?(Required)

Are you up to date with your cervical screening?(Required)

Have you ever had an abnormal smear?(Required)

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

Do you have any other medical conditions?(Required)

If yes, please give details...

Do you take any medication?(Required)

If yes, please give details...

Are you allergic to anything?(Required)

If yes, please give details...

Is there any other information you would like to tell us that you think might be important or helpful? e.g. did you faint or feel faint at your last coil fit; was a General Anaesthetic required; any specific pain relief requests; is it for HRT or non-contraceptive use…?

What would be your preferred clinic?(Required)

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

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 an SMS 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 an SMS, please check the box.

You can access a helpful video on coil fitting via the following link: https://vimeo.com/36869451

Link to patient information leaflet on copper coil: https://www.contraceptionchoices.org/contraceptive-method/copper-coil-iud

Link to patient information leaflet on hormonal coil: https://www.contraceptionchoices.org/contraceptive-method/hormonal-coil-ius

Further information:

For women wanting a coil exchange whose coil is in date, please abstain from sex or use condoms reliably for 7 days prior to the procedure. For women wanting a coil exchange whose coil is out of date, please abstain from sex or use condoms reliably for 21 days prior to the procedure.  Please be prepared to provide a urine specimen on the day, prior to 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 prior to the appointment.  You may wish to take some painkillers 1 hour prior to your appointment.  It is advisable to bring a sanitary towel or pantyliner to your appt in case of any bleeding afterwards.  You can change your mind about which coil you decide to have fitted on the day.  Please do not bring any children to the appointment