Intrauterine (Coil) Contraception Self-Assessment

If you have been asked by the practice to submit an Intrauterine (Coil) Contraception Self-Assessment, please complete this form.

Intrauterine (Coil) Contraception Self-Assessment

Patient Details

Required field(s) are indicated by *

Please use the format DD/MM/YYYY

It is important that you are suitably informed prior to the fitting of your intrauterine device (IUD) or intrauterine system (IUS). Please confirm the following:

I have read the information on intrauterine contraception provided *
I understand that no method is 100% effective and that there is a small risk of failure (less than 1 in 100 chance of pregnancy; 1 in 2000 chance of having an ectopic pregnancy) *
I understand that there is a small risk of pelvic infection (less than 1 in 100) in the first few weeks after insertion of the device *
I understand there is a 1 in 20 chance of the device being expelled / falling out and that this may go un-noticed *
I understand that there is a risk of perforation of the womb at the time of insertion of the device and if this happens I may require an operation in hospital to remove the device *
I understand that the risk of perforation for most women is approximately 1 in 1000, this risk is higher if within 9 months of having a baby or during breastfeeding
I understand that if breastfeeding the risk of perforation increases to approximately 6 in 1000

I understand that the copper IUD may make my periods heavier, longer and/or more painful *
I understand that the IUS may cause; irregular bleeding or spotting for a few months after which lighter or no periods is common, some hormonal side effects, particularly in the first few months of use *

Radio Buttons
Smoking Status:
Would you like help to quit smoking?

Blood Pressure

I understand that it is not safe to insert an IUD/IUS if there is a risk of pregnancy
I am not at risk of pregnancy because: *