Sexual Health - IUCD Fitting Form

What contraception are you currently using?

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?

Yes

No

Do you currenly have any medical conditions?

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

Yes

No

Do you think you might be pregnant?

Yes

No

Are you breastfeeding?

Yes

No

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

Yes

No

Was the sex..

Protected (condom used)

Unprotected (no condom)

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

0

1

2 - 4

5 +

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

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

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

Sexual Health - IUCD fitting form