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Coil (IUD/IUS) fitting pre-appointment questionnaire

Coil (IUD/IUS) fitting pre-appointment questionnaire

Section

Appointment request

What would you like the appointment for?

If you’re unsure which coil is best for you, please read:

Your health

Do you have any long term health conditions?
Are you taking any regular medication?
Do you have any allergies?
For example, latex, copper, anaesthetic

Pregnancy risk

What contraception are you using currently?
Have you had unprotected sex in the last 3 weeks?
Do you think there is any chance you could be pregnant?
Have you taken a pregnancy test in the past 7 days?
What was the result of the pregnancy test?

Preparation checklist

Please read the following:

  • I understand that I must not be at risk of pregnancy before coil fitting.
  • I have used reliable contraception or avoided sex as advised before the appointment.
    • If this is my first coil, I have abstained from sex or used contraception for 3 weeks.
    • If I already have a coil, I have used condoms or abstained for 7 days.
  • I will continue using contraception for 7 days after the new coil is fitted.
  • I have taken or will take painkillers (e.g. ibuprofen or paracetamol) before my appointment.
  • I will eat something and drink fluids before coming to the clinic.
  • I will not bring children or babies with me to the appointment.
Confirmation

Consent and understanding

Please read the following:

  • I understand that the coil will not be fitted if there is a risk of pregnancy.
  • I understand that no method is 100% effective and a small chance of failure exists.
  • I am aware of the small risks: infection, expulsion, perforation, and ectopic pregnancy.
  • I understand the coil does not protect against STIs – condoms are advised with new partners.
  • I understand I may have bleeding and cramping afterwards, and I may need to rest.
Confirmation