Belfast Private GP Coil Questionnaire & Consent

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

What coil service do you require?*

If you are uncertain which coil is best for you - please read more about the different types of coils.

IUS -www.nhs.uk/ius-intrauterine-system

IUD -www.nhs.uk/iud-coil

Select if you have any of the following conditions*

Ovarian, Cervical, Womb or Breast Cancer?Are you currently taking hormone replacement therapy or do you plan to start this?Heart problems?Epilepsy or SeizuresNone of above

Select if the below statements relate to you*

Been told you have a condition of your womb (e.g. fibroids, heart shaped womb, septate womb)?Had any pelvic surgery or surgery on the womb including endometrial resection or ablation (removal of the lining of the womb)?Had any procedures on your cervix (other than routine cervical smears)?None of above

List any Medication you may be taking

Any Allergies to drugs or latex?*

Before a coil is fitted it is important that there is no chance that you are or might be pregnant.

Please ensure that you use consistent and reliable contraception or abstain from sexual intercourse for 3 weeks before the coil fitting. You need to continue additional contraception for 7 days after your coil has been fitted.

A pregnancy test will be carried out before your coil fit. To rely on a negative result, effective contraception or abstinence from sex is required for the 3 weeks before the pregnancy test.

My current contraception is:

Please tick if any of the below apply to you. Please continue your current method for contraception until the coil fitting and for 7 days after:*

I have a contraceptive implant that has not run outI had a contraceptive injection that has not run outI have a coil that has not run outI have been using pills or patches with no problems or forgotten pillsI have been using condoms every time and have had no split condoms or problemsI am not currently sexually activeNone applicable

Please tick if any of the below apply to you then please abstain from sexual intercourse or use a condom every time for at least 3 weeks before your appointment and for 7 days after:*

I have an IUD or IUS fitted that has run outI have an implant that has run outMy contraceptive injection is overdueI have taken emergency contraception in the last monthI have forgotten 1 or more pills or left my patch off or had a broken condomI am using the withdrawal method, natural family planning or no contraceptionNone applicable

Date of you last Period?

Date

Please select any statements if relevant to you*

Have any bleeding in between your periods?Bleed after sex?Periods recently changed to become much heavier than usual, passing clots or flooding through towels/tampons?None applicable

If any of the questions below are true for you you will need to have STI (sexually transmitted infection) testing for gonorrhoea and chlamydia before having your coil fitted and have the results available at least a week before your coil fit appointment. This is in line with guidelines. If this is the case we can help you arrange.*

Sexually active and aged under 25Had a new sexual partner in the last 3 months?Have you had more than one sexual partner in the last year?Have a regular sexual partner who has other sexual partners?Have a history of STI or a recent contact of someone with an STI?Are you concerned that your sexual partner may have a sexually transmitted infection?Have any pelvic pain, vaginal discharge or change in bleeding pattern?None applicable

Advice Pre Procedure

Please bring a urine sample, bottle of water and sanitary pad to the appointment. Please take some painkillers an hour before the procedure (either ibuprofen 400mg (with or after food) or paracetamol 1g- or both-as long as you are not allergic to these) as some women experience discomfort, like period cramps, during coil insertions.

Some women can feel a little faint during and after the fitting. Please have your normal breakfast and something to drink before you come to help avoid this. You may wish to have a friend or relative travel with you or drive you home after the appointment. Due to the current covid restrictions, you will be asked to come into the procedure room alone. There will be a doctor and a nurse present. Children and babies cannot be present during the procedure. If children are brought to the appointment the procedure will be cancelled.

For coil replacements it is rare that a new coil cannot be fitted in the same appointment. In case this happens we would ask that replacement coil patients abstain from unprtected intercourse the week preceding appointment. That way there is no risk of unplanned pregnancy if the inserted cannot replace the coil.

Please wear loose, comfortable clothes and footwear for your appointment.

Remember, you can change your mind about having a coil fitted at any time.

The Fitting Process

Please allow 30 minutes for the appointment.

If at any stage you change your mind about the fitting, the procedure can be stopped.

The process of fitting a coil is similar to what happens with a smear test but takes longer and can be more uncomfortable.
A vaginal examination will be undertaken and then the coil fitted. You may feel some discomfort, but this varies from person to person. The doctor will do their best to reassure you and make the procedure as pleasant as it can be.

You will be taught how to check your threads.

After the procedure, you will be advised to sit in the waiting room for 10 – 15 minutes to make sure you continue to feel well.

Please ensure you have no major commitments afterwards as you may need to take it easy and relax for the rest of the day.

After the Fitting

Use additional contraception (eg condoms) for 7 days.

You may experience bleeding or cramping. Continue with regular painkillers if required. If the pain is more uncomfortable than a period, talk to a doctor.

Avoid tampons for the first week, but thereafter it is ok to use them.

If you have any concerns after your coil fitting, please do not hesitate to contact the surgery for advice.

Possible Risks

Discomfort/dizziness/fainting on insertion
Infection
Failure resulting in a pregnancy in the womb(uterus) or in the tubes (Ectopic pregnancy
Damage to cervix or womb including perforation
Expulsion (coil comes out of the womb) or displacement (change of position)
Altered vaginal bleeding (IUD- heavier, more painful or prolonged periods, IUS- erratic bleeding up to 6 months)
IUS- hormonal effects- greasy skin, bloating breast tenderness
Before you attend your fit appointment, please make sure that you are aware and agree with the following statements:

I have completed this form myself.
I have read the information about the IUD and IUS.
I have followed the advice about contraception or not having sex for 3 weeks before the procedure and for 7 days after.
I have checked whether I need an STI screen.
If I need to have a STI screen, I will ensure I have my results before I attend for my fitting appointment.
I understand that the clinician will not fit the IUD / IUS if they are concerned that I may be pregnant.
I understand that an IUD / IUS may fail as contraception in 2-5 women in every 1000 that have them fitted. If it does fail there is a risk that the pregnancy will not be in the womb (ectopic pregnancy).
I understand that there is a risk of infection of 1 per 100 women in the first few weeks after insertion.
I understand that an IUD/ IUS will not protect me against STIs and condoms are recommended too, especially if I have a new sexual partner.
I understand that there is a 1 in 20 chance of the device falling out (expulsion) or displacement.
I understand that the risk of uterine perforation (hole in the womb) is 1-2 per 1000 women. In breastfeeding women, the risk is 6-12 per 1000 women.
I understand that sometimes an IUD/IUS cannot be refitted after removal due to cervical spasm and if this happens a further appointment may be offered.
I understand my bleeding pattern will change.
IUD – my periods may be heavier and longer and will take 3 – 6 months to settle.
IUS – my periods may get lighter or stop but I may have erratic bleeding and spotting for the first 3 – 6 months.
I will have breakfast and a drink prior to the fitting appointment.
I will bring a bottle of water to the appointment.
I will not bring children/babies to the appointment.
I understand that if I wish to take painkillers, I should do so an hour before the appointment.
I understand that I am likely to bleed after the fitting and will need a sanitary pad.
I can use my menstrual cup or tampons from 3 weeks after fitting to allow the threads to settle.
It is common to have period pain after fitting and some people like to rest.

Consent*

I am aware and agree with the statements above.

Signature*