IUD Intake Form

Your initials

Chart #

Have you had an IUD before?

• Yes
• No, I have not had an IUD before

If Yes, what Kind of IUD?HormonalCopperOther

Choose the best answer

Is this an IUD for EMERGENCY CONTRACEPTION?

• Yes
• No

If Yes, WHEN was the unprotected sex? ( Approximate date )

When was the first day of your last period? ( day / month / year )

For your periods what do you use?

• Tampons
• Pads
• A Cup (eg. Diva)
• Sponge

How heavy is your usual period?

• Light
• Moderate
• Heavy
• Very Heavy

How many days does your period usually last?

How would you rate your WORST period cramps on a scale of 0-10?

Selected Value: 0

10 is the worst

How would you rate your USUAL period cramps on a scale of 0-10?

Selected Value: 0

10 is the worst

Have you ever been pregnant?

• Yes
• No

How many Births?012345More than 5

Births - choose a #

How many Abortions?012More than 2

Abortions

How many Miscarriages?012More than 2

Miscarriages

How many Tubal / ectopic?012More than 2

Tubal / ectopic

Have you ever had an infection in your uterus or fallopian tubes, or a sexually transmitted infection, (e.g. gonorrhea, chlamydia, PID)?

• Yes
• No

How many sexual partners have you had in the past year?012 - 55+

# of sexual partners

When was your last PAP smear test (routine cervical cancer check)?

month / year - PAP

Do you have any medical illnesses (diabetes, heart disease, etc)?

• Yes
• No

If Yes, please list illnesses:

Are you taking any medication?

• Yes
• No

If Yes, please list medications:

Are you allergic to any medication?

• Yes
• No

If Yes, please list:

Email

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