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

The checklist consists of 23 questions designed to identify diseases and high-risk behaviors that would prevent safe use of hormonal IUD or require additional assessments. Patients who are excluded because of their response to some of the questions that determine medical eligibility may still be eligible to use the hormonal IUD, if the alleged disease can be ruled out through proper evaluation.

A health care provider should complete the checklist before putting the hormonal IUD. In some contexts, the responsibility to complete the checklist can be shared by a counselor to complete questions 1 to 16 and a provider of health care trained to determine the answers to the remaining questions during the pelvic exam.

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

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