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

Intrauterine contraceptive device review

Intrauterine Contraceptive Device Review

Required fields are labelled

You must be aged 13 or over to complete this form yourself

What is your name? Required

First name

Last name

What is your date of birth? Required

For example, 31 3 1980

Day

Month

Year

What is your sex? Required

As recorded on your medical record

Male

Female

Other

What is your postcode? Required

The one used to register with your GP

What is your phone number? Required

What is your email address? Required

Anyone else with access to your email account may see responses sent to you

Is this for a new IUCD or would you like your IUCD replaced or removed? Required

New IUCD

IUCD Replaced

Please indicate why you would like your IUCD replaced: Required

Are you able to feel your threads? Required

Yes

No

Please specify what IUCD you want/have: Required

Mirena

Copper

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

When does your current IUCD expire? Required

Smoking

Smoking Status: Required

Smoker

Ex smoker

Never smoked tobacco

Never smoked

Please specify: Required

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? Required

Yes

No

Ex user

Review

Height (in cm): Required

Weight (in kg): Required

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

Date of last menstrual period: Required

Please use the format DD/MM/YYYY.

Has your bleeding changed? If so, how? Required

Do you have amenorrhoea (no periods)? Required

Yes

No

Do you bleed after sex? Required

Yes

No

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

Please state ‘N/A’ if not applicable.

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

Please state ‘N/A’ if not applicable.

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

Yes

No

Have you had any abnormal cervical screening in the past, or treatments/operations to your cervix?

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

How long have you been with your current partner? Required

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

Yes

No

N/A

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

Please state ‘N/A’ if not applicable.

Please specify how many pregnancies you have had, and if these were normal vaginal delivery, caesarean section, miscarriages, or termination of pregnancy: Required

Please state ‘N/A’ if not applicable.

Please specify any other medications that you take: Required

Please state ‘N/A’ if not applicable.

Please specify any known allergies: Required

Please state ‘N/A’ if not applicable.

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

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

Get directions

01953 602220

About the surgery

Register with the surgery

Sick (fit) notes

Feedback and complaints

Wymondham Medical Partnership

CQC overall rating

Good

6 February 2018

See the report

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