Coil Form

Full Name

Date of Birth

Address

Contact Number

When was your last proper menstrual period?

Do you have any irregular bleeding?

Yes

No

Do you have any previous/current gynaecological conditions?

Yes

No

If yes, please state (optional)

What is your current method of contraception and when was it initiated?

Is there any risk of pregnancy? e.g. unprotected sexual intercourse after last period, any missed contraception and unprotected sexual intercourse.

Yes

No

Are you currently breastfeeding?

Yes

No

Have you recently had a baby in the last month?

Yes

No

Have you previously been tested for sexually transmitted infections?

Yes

No

If yes, when? (optional)

Do you have any allergies?

Yes

No

If yes, please state. (optional)

What coil would you like to use?

Have you had any complications after previous coil insertions?

Yes

No

If yes, please state. (optional)

Are you taking HRT?

Yes

No

If yes, please state. (optional)

Are you taking any vaginal moisturisers/pessaries?

Yes

No

If yes, please state. (optional)

This form collects your name, date of birth, other personal information and medical details. This is to confirm you are registered with the practice, to allow Waterfront Medical Centre to contact you, and to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy for more information on how we protect and manage your submitted data. I consent to Waterfront Medical Centre collecting and storing my data submitted via this form.

Yes

Waterfront Medical Centre

Personal Details

Further Information

Consent