Intrauterine contraception self-assessment Intrauterine contraception self-assessment Name First Last Date of Birth MM slash DD slash YYYY I have watched the CNWL online video on intrauterine contraception ?Yes No I understand that no method is 100% effective and that there is a small risk of failure (less than 1 in 100 chance of pregnancy; 1 in 2000 chance of having an ectopic pregnancy)Yes No I understand that there is a small risk of pelvic infection (less than 1 in 100) in the first few weeks of insertion of the deviceYes No I understand that there is a 1 in 20 chance of the device being expelled / falling out and that this may go un-noticedYes No I understand that – there is a risk of perforation of the womb at the time of insertion of the device and if this happens I may require an operation in hospital to remove the device, the risk of perforation for most women is approximately 1 in 1000, this risk is higher if within 9months of having a baby or during breastfeeding , if breastfeeding the risk of perforation increases to approximately 6 in 1000Yes No If having a Copper IUD: I understand that the copped IUD may make my periods heavier, longer and/or more painfulYes No If having a Hormone IUS: I understand that the IUS may cause: irregular bleeding or spotting for a few months after which lighter or no periods is common, some hormonal side-effects, particularly in the first few months of useYes No I understand that it is not safe to insert an IUD/IUS if there is a risk of pregnancyI am not at risk of pregnancy because:I am using a method of contraception correctly I have not had vaginal sex since the beginning of my lastperiod I have not had vaginal sex for at least 3 weeks Do you use a mooncup?Yes No If you are having periods, what date was the first day of your last period? Optional MM slash DD slash YYYY What method of contraception have you used most recently? Signature Optional