Coil Fitting Appointment Questionnaire

First Name *

Last Name *

Address (including postcode)

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

CHI Number

This is the 10 digit number you will find included in any documents from health services, such as appointment letters. You can also contact your GP surgery to ask for your CHI Number.

Phone Number *

GP Practice

Coil Requested

Mirena (contraception/HRT/heavy periods)

Kyleena (contraception/no previous pregnancy)

Copper (5yr- 10yr – no hormone, no period benefit)

Unsure

Do you have a current coil?

Yes

What type of coil is it?

Current contraception

Please continue with your current contraception for 1 week AFTER coil is fitted.

Date of last smear

Result of last smear

Normal

Awaiting treatment

OtherOther

Any previous treatment or surgery to cervix e.g. at colposcopy clinic?

Yes

Please tell us what treatment and when you recieved it

Any Sexually Transmitted Infection in the past e.g. chlamydia, gonorrhoea?

Yes

Date(s) of infection

New Sexual Partner in past 3 months?

Yes

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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Coil Fitting Appointment Questionnaire

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