Coil (IUD/IUS) Pre-Fitting Counselling Questionnaire

Coil (IUD/IUS) Pre-Fitting Counselling Questionnaire

Please complete this form and a Practice Nurse will be in contact to book you in for your appointment 

  • YOUR DETAILS

    Date of Birth
    For example, 15 3 1984

  • REASON FOR APPOINTMENT

    What is your main reason for wanting a coil?
    Which type of coil are you interested in?

  • PREGNANCY ASSESSMENT

    What was the first day of your last menstrual period? (optional)
    For example, 15 3 1984
    Have you had unprotected sexual intercourse since your last period? (optional)
    Is there any possibility that you could be pregnant? (optional)
    Have you recently had a baby, miscarriage, abortion, or ectopic pregnancy? (optional)

  • MEDICAL AND GYNAECOLOGICAL HISTORY

    Have you ever used a coil before? (optional)
    Do you have any of the following? (optional)
    HAVE YOU EVER HAD: (optional)
    Do you have any significant medical conditions or allergies? (optional)

  • SEXUAL HEALTH ASSESSMENT

    Have you had a new sexual partner within the last 12 months? (optional)
    Do you think you may be at risk of a sexually transmitted infection (STI)? (optional)

  • THE PROCEDURE

    PLEASE CONFIRM IF YOU UNDERSTAND THE FOLLOWING?

    How the coil works (optional)
    Alternative contraceptive options (optional)
    Expected changes to bleeding patterns (optional)
    Risks of fitting (pain, infection, expulsion, perforation) (optional)
    What happens during the fitting procedure (optional)
    Aftercare and warning signs (optional)
    When the coil becomes effective (optional)

  • PATIENT QUESTIONS AND CONCERNS

  • ADDITIONAL INFORMATION

     

     The Local Sexual Health Service: Riverside Clinic, located at Gravesham Community Hospital on Bath Street (DA11 0DG). It offers free, confidential STI testing, treatments, and contraception. Book or triage via 0300 373 0709

     

    Free Home Tests: https://www.nhs.uk/services/service-directory/sh24-online-sexual-health-test-kit-ordering-service/N10969814

  • CONSENT TO PROCEED WITH BOOKING /FITTING

    By submitting this form I am consenting to be booked in for my coil fitting

    I can confirm that I have had the opportunity to ask questions and discuss alternatives, and that I understand the benefits and risks. 

    I understand I need to ensure I have eaten ahead of the fitting and have taken adequate analgesia (Paracetamol / Ibuprofen)

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Page last reviewed: 26 August 2026