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Wymondham Medical Partnership Caring for our patients whilst helping them to care for themselves

Contraceptive implant review

Contraceptive Implant Review

Section

Is this for a new implant or would you like your implant replaced or removed? *

New implant

Replaced implant

Removal of implant

Please indicate why you would like your implant removed: *

What are you currently using for contraception, and are you using this consistently and correctly? *

When does your current implant expire? *

Are you able to palpate both ends of the implant in the arm? *

Yes

No

Smoking

Smoking Status: *

Smoker

Ex smoker

Never smoked tobacco

Never smoked

Please specify: *

Light cigarette smoker (1-9 per day)

Moderate cigarette smoker (10-20 per day)

Heavy cigarette smoker (20-39 per day)

Very heavy cigarette smoker (40+ per day)

Do you use an electronic cigarette? *

Yes

No

Ex user

Review

Height (in cm): *

Weight (in kg): *

Do you have a regular menstrual cycle and how long is it? *

Date of last menstrual period: *

Please use the format DD/MM/YYYY.

Has your bleeding changed? If so, how? *

Do you have amenorrhoea (no periods)? *

Yes

No

Do you bleed after sex? *

Yes

No

Please specify any personal history of breast cancer, thrombosis, heart problems, strokes or liver problems: *

Please state ‘N/A’ if not applicable.

Please specify any family history of breast cancer, thrombosis, heart problems, strokes or liver problems: *

Please state ‘N/A’ if not applicable.

If you are over the age of 24, have you had a cervical screening?

Yes

No

What was the date of your last cervical screening?

Please use the format: DD/MM/YYYY.

How many sexual partners have you had in the last 12 months? *

How long have you been with your current partner? *

Have you had a screening for sexually transmitted infections within your current relationship? *

Yes

No

N/A

Have you been tested or treated for a sexually transmitted infection in the past? (please specify) *

Please state ‘N/A’ if not applicable.

Please specify any other medications that you take: *

Please state ‘N/A’ if not applicable.

Please specify any known allergies: *

Please state ‘N/A’ if not applicable.

Do you have any concerns regarding domestic abuse/violence? *

Yes

No

If you are aged 13-24 are you C-Card (condom card) registered?

Yes

No

Would you like more information or to be registered?

Yes

No

Whilst your record remains confidential if someone such as your parent or guardian has access to your online record they may be able to view this and future consultations online.

If you are human, leave this field blank.

Postmill Close
Wymondham
Norfolk
NR18 0RF

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01953 602220

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