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Sexual Health - IUCD fitting form

It is essential that this form is filled out prior to your GP booking you into a IUCD fitting appointment. Once this form has been completed, one of our members of staff will be in touch to get you booked in. Should you have any queries or issues, please give us a call on 0161 368 5426

Form:

First Name

Date of Birth

Last Name

GP Practice

Phone

Address

Message

If other please specify

What type of referral are you making? *

Exchange

New insertion

Removal

I confirm I would like an IUCD fitted for the purpoes of contraception.

What contraception are you currently using? * Required

Combined hormonal contraception (Pills/Patch/Ring)

Progestogen only contraception (Injection/Implant/Pill/IUCD)

Non-hormonal contraception (condoms/copper coil/ diaphragm or cap)

None - (withdrawal, natural family planning, ovulation tracker)

Do you need an interpreter at the face to face appointment? * Required

Yes

No

Do you currenly have any medical conditions? * Required

Epilepsy

Cancer of any type

Heart disease

High cholesterol

Organ transplant

Unexpected vaginal bleeding

Molar pregnancy

Sexually transmitted infection such as PID

Fibroids or abnormality of the womb

Pelvic TB

HIV

None of the above

Other:

Are you taking any medication that you have been prescribed or bought over the counter? * Required

Yes

No

Do you think you might be pregnant? * Required

Yes

No

Are you breastfeeding? * Required

Yes

No

Do you have any drug or othe allergies? (Including peanut, soya or lactose) * Required

Yes

No

If yes please specify:

How often do you have periods and when was your last one?

Are your periods painful or heavy?

When was the last time you had any sexual contact with anyone?

Was the sex..

Protected (condom used)

Unprotected (no condom)

Have you had any new sexual partners in the last 3 months? * Required

0

1

2 - 4

5 +

Are any of the following applicable to you in the last 3 months? * Required

Have you had a sexual partner from another country/region other than Western Europe

Do you have any tattoos or piercing that have been done unprofessionally (stick and poke / bamboo tattoo / prison tattoo)?

Have you been paid for sex?

Have you paid for sex?

Have you received any medical treatment in another country (operation/blood transfusion/injection)?

Have you had a blood transfusion?

None of the above

If yes to any of the above please detail...

Do you smoke/vape or have you smoked/vaped in the last year?

Alcohol use:

Are you currenly or have you ever experienced any of the below? * Required

Sexual assault

Domestic abuse

Mental health issues

I do not want to answer

This is not applicable to me

Thank you for submitting all required information.!

0161 368 5426

Healthy Hyde Body & Mind

Clarendon Square Shopping Mall

SK14 2QT

©2024 by Healthy Hyde.

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