Checklist for examining patients who wish to start using the copper IUD

The checklist consists of 21 questions designed to identify diseases and high-risk behaviors that would prevent safe IUD use or require further evaluation. Patients who are excluded because of their response to some of the questions that determine medical eligibility may still be eligible to use an IUD, if the alleged disease can be ruled out through proper evaluation.

A health care provider should complete the checklist before inserting an IUD. In some situations, the responsibility to complete the checklist can be shared by a counselor to complete questions 1 to 14 and a provider of health care trained to determine the answers to the remaining questions during the pelvic exam. Among the providers trained to insert an IUD may include nurses, nurse midwives, nurse practitioners, midwives, doctors and, according to the educational and professional standards of each country, medical assistants and associates.

Clinical Guidelines
Family Planning
Health Care Workers
FHI 360
U.S. Agency for International Development

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