{"type":"doc","content":[{"type":"extension","attrs":{"layout":"default","extensionType":"com.atlassian.confluence.macro.core","extensionKey":"toc","parameters":{"macroParams":{},"macroMetadata":{"macroId":{"value":"dff291cc-f3f5-4c64-9c77-478737fc885c"},"schemaVersion":{"value":"1"},"title":"Table of Contents"}},"localId":"55d8317e-86bf-46d2-a9a8-72ee0e842921"}},{"type":"heading","attrs":{"level":3},"content":[{"text":"Key Objectives","type":"text"}]},{"type":"paragraph","content":[{"text":"Provide patients with information about their procedure and collect information from the patient before their appointment to reduce clinic time and to support patient empowerment.","type":"text"}]},{"type":"heading","attrs":{"level":3},"content":[{"text":"Outcome measures","type":"text"}]},{"type":"paragraph","content":[{"text":"Equip patients with the information they need before their appointment, also providing the tools they need to interact digitally rather than relying on face to face consultations.","type":"text"}]},{"type":"heading","attrs":{"level":3},"content":[{"text":"Current Baselines","type":"text"}]},{"type":"paragraph","content":[{"text":"The patient arrives at the clinic. Information is explained to the patient and the nurse goes through a questionnaire/checklist with the patient, appointments aren’t being efficient and patients are having long waiting times.","type":"text"}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Workflow","type":"text"}]},{"type":"mediaSingle","attrs":{"layout":"center"},"content":[{"type":"media","attrs":{"width":1280,"id":"5a9d3256-cb97-4a1c-aaf1-008bf344af22","collection":"contentId-3590881572","type":"file","height":707}}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Coil fitting checklist care plan","type":"text"}]},{"type":"mediaSingle","attrs":{"layout":"center"},"content":[{"type":"media","attrs":{"width":1280,"id":"0cbe50f5-d91b-4460-9850-3bf10d26aaf6","collection":"contentId-3590881572","type":"file","height":4441}}]},{"type":"expand","attrs":{"title":"Example care plan template code for Coil fitting checklist Care Plan HTML"},"content":[{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

Coil fitting checklist - for intrauterine devices (IUD) and intrauterine systems (IUS)

","type":"text"}]},{"type":"paragraph","content":[{"text":"

Please complete this checklist to ensure that we are able to fit your coil at your booked","type":"text"}]},{"type":"paragraph","content":[{"text":"appointment. This checklist will also provide you with some important information about","type":"text"}]},{"type":"paragraph","content":[{"text":"having a coil fitted.

","type":"text"}]},{"type":"paragraph","content":[{"text":"

Please watch the video below or read the contraception","type":"text"}]},{"type":"paragraph","content":[{"text":"Choices website before completing this form.

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

Please tick the boxes to confirm that you have understood and are ready to book your coil fitting appointment:

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I have watched the video above on coils or I have read the contraception","type":"text"}]},{"type":"paragraph","content":[{"text":"Choices website or I already have an IUD/IUS and am familiar with this contraception method

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I am using an effective method of contraception and haven't had any problems eg burst condom, missed pills, IUD overdue for change.

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I have not had unprotected sex (or used the withdrawal method) since my last period.

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I understand that it is not safe to insert an IUD/IUS if I might be pregnant.

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I will make sure that I have eaten on the day of the appointment. (You may also wish to take an over-the-counter","type":"text"}]},{"type":"paragraph","content":[{"text":"painkiller 30 minutes before your appointment.)

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I understand that an IUD/IUS is more than 99 per cent effective (less than 1 in 100 chance of pregnancy).

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I understand that there is a small risk (1 in 1,000) that the IUD/IUS might go through (perforate)","type":"text"}]},{"type":"paragraph","content":[{"text":"my womb or cervix when it is put in. If this does happen, the IUD/IUS may have to be removed surgically.

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I understand that there is a 1 in 20 chance of the device falling out.

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I understand that there is a small risk of infection (1 in 100) in the first 20 days following insertion of a device.

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I know that a copper IUD will make my periods slightly heavier, longer and more painful.

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I know that an IUS will make my periods much lighter but causes erratic bleeding and spotting in the first few months of use.

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I do not believe I am at risk of sexually transmitted infections (STIs) or I have been tested negative recently for","type":"text"}]},{"type":"paragraph","content":[{"text":"Chlamydia / Gonorrhoea. Risk factors for STI are having a new partner in the last 3 months or more than one partner","type":"text"}]},{"type":"paragraph","content":[{"text":"in the last year - we recommend you have a negative test before the procedure. Order yours at","type":"text"}]},{"type":"paragraph","content":[{"text":"Frisky Wales

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Sub-dermal implant insertion checklist care plan","type":"text"}]},{"type":"paragraph"},{"type":"heading","attrs":{"level":3},"content":[{"text":"Key Objectives","type":"text"}]},{"type":"paragraph","content":[{"text":"Provide patients with information about their procedure and collect information from the patient before their appointment to reduce clinic time and to support patient empowerment.","type":"text"}]},{"type":"paragraph"},{"type":"heading","attrs":{"level":3},"content":[{"text":"Outcome measures","type":"text"}]},{"type":"paragraph","content":[{"text":"Equip patients with the information they need before their appointment, also providing the tools they need to interact digitally rather than relying on face to face consultations.","type":"text"}]},{"type":"paragraph"},{"type":"heading","attrs":{"level":3},"content":[{"text":"Current Baselines","type":"text"}]},{"type":"paragraph","content":[{"text":"The patient arrives at the clinic. Information is explained to the patient and the nurse goes through a questionnaire/checklist with the patient, appointments aren’t being efficient and patients are having long waiting times.","type":"text"}]},{"type":"mediaSingle","attrs":{"layout":"center","width":65.0},"content":[{"type":"media","attrs":{"width":1280,"id":"1260cc5d-bdf4-43ca-b8a8-6610bf9ea8ba","collection":"contentId-3590881572","type":"file","height":3870}}]},{"type":"expand","attrs":{"title":"Example care plan template code for Sub-dermal implant insertion Care Plan HTML"},"content":[{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

Sub-dermal implant insertion checklist

","type":"text"}]},{"type":"paragraph","content":[{"text":"

Please complete this checklist to ensure that we are able to fit your implant at your booked","type":"text"}]},{"type":"paragraph","content":[{"text":"appointment. This checklist will also provide you with some important information about","type":"text"}]},{"type":"paragraph","content":[{"text":"having an implant inserted.

","type":"text"}]},{"type":"paragraph","content":[{"text":"

Please watch the video below or read the contraception","type":"text"}]},{"type":"paragraph","content":[{"text":"Choices website before completing this form.

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"","type":"text"}]},{"type":"paragraph","content":[{"text":"

(courtesy of Worcestershire Health and Care NHS Trust)

","type":"text"}]},{"type":"paragraph","content":[{"text":"

Please tick the boxes to confirm that you have understood and are ready to book your implant insertion appointment:

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I have watched the video above on implants or I have read the contraception","type":"text"}]},{"type":"paragraph","content":[{"text":"Choices website or I already have an implant and am familiar with this contraception method

","type":"text"}]},{"type":"paragraph","content":[{"text":"Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I am using an effective method of contraception and haven't had any problems eg burst condom, missed pills, IUD/Coil or Implant overdue for change

","type":"text"}]},{"type":"paragraph","content":[{"text":"Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I have not had unprotected sex (or used the withdrawal method) since my last period.

","type":"text"}]},{"type":"paragraph","content":[{"text":"Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I understand that an implant is more than 99 per cent effective (less than 1 in 1000 chance of pregnancy).

","type":"text"}]},{"type":"paragraph","content":[{"text":"Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I understand that the Implant may alter my bleeding pattern, and that I may experience no bleeding,","type":"text"}]},{"type":"paragraph","content":[{"text":"or have irregular bleeding especially in the first few months.

","type":"text"}]},{"type":"paragraph","content":[{"text":"Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I understand that medications such as some of those used to treat epilepsy, HIV and TB, and the","type":"text"}]},{"type":"paragraph","content":[{"text":"complementary medicine St John's Wort, may make the Implant less effective

","type":"text"}]},{"type":"paragraph","content":[{"text":"Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I understand that if a new Implant is inserted outside of day 1-5 of the menstrual cycle, it is not","type":"text"}]},{"type":"paragraph","content":[{"text":"effective for 7 days and I should use another method of contraception, such as condoms.

","type":"text"}]},{"type":"paragraph","content":[{"text":"Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If there is a risk of pregnancy at the time my implant is fitted I should do a pregnancy","type":"text"}]},{"type":"paragraph","content":[{"text":"test at 4 weeks after the insertion

","type":"text"}]},{"type":"paragraph","content":[{"text":"Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

I do not believe I am at risk of sexually transmitted infections (STIs) or I have been tested","type":"text"}]},{"type":"paragraph","content":[{"text":"negative recently for Chlamydia / Gonorrhoea. Risk factors for STI are having a new partner in","type":"text"}]},{"type":"paragraph","content":[{"text":"the last 3 months or more than one partner in the last year. Order a free test at","type":"text"}]},{"type":"paragraph","content":[{"text":"Frisky Wales

","type":"text"}]},{"type":"paragraph","content":[{"text":"Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Contraceptive Pill Checklist care plan","type":"text"}]},{"type":"heading","attrs":{"level":3},"content":[{"text":"Key Objectives","type":"text"}]},{"type":"paragraph","content":[{"text":"Provide patients with information about their procedure and collect information from the patient before their appointment to reduce clinic time and to support patient empowerment.","type":"text"}]},{"type":"paragraph"},{"type":"heading","attrs":{"level":3},"content":[{"text":"Outcome measures","type":"text"}]},{"type":"paragraph","content":[{"text":"Equip patients with the information they need before their appointment, also providing the tools they need to interact digitally rather than relying on face to face consultations.","type":"text"}]},{"type":"paragraph"},{"type":"heading","attrs":{"level":3},"content":[{"text":"Current Baselines","type":"text"}]},{"type":"paragraph","content":[{"text":"The patient arrives at the clinic. Information is explained to the patient and the nurse goes through a questionnaire/checklist with the patient, appointments aren’t being efficient and patients are having long waiting times.","type":"text"}]},{"type":"paragraph"},{"type":"heading","attrs":{"level":2},"content":[{"text":"Workflow","type":"text"}]},{"type":"orderedList","attrs":{"order":1},"content":[{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Admin: calls patient offering appointment and PKB","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Admin: creates an appointment and adds care plan into PKB","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"PKB: notifies patient about appointment and care plan are in their record","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Patient: fills in informed questionnaire care plan before the appointment","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Patient: attends appointment for contraceptive pill advice and prescription","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Professional: reviews answers in the care plan","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Professional: prescribes the contraceptive pill","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Professional: team-based messaging available to the patient for follow up instructions and questions","type":"text"}]}]}]},{"type":"mediaSingle","attrs":{"layout":"center","width":65.0},"content":[{"type":"media","attrs":{"width":1280,"id":"8d215d19-e4ac-42c8-bedc-06338550f8a2","collection":"contentId-3590881572","type":"file","height":9688}}]},{"type":"heading","attrs":{"level":3},"content":[{"text":"Evaluation","type":"text"}]},{"type":"bulletList","content":[{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Reducing phone calls and contacts","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Patient reduce coming back in for more contraception","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"The ability for patients to contact the team if they have any issues after starting the contraceptive pill","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Women able to track symptoms in relation to the contraceptive pill","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Record weight","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Record BP when they get it checked at the GP","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Library of different contraception options","type":"text"}]}]}]},{"type":"expand","attrs":{"title":"Example care plan template code for Contraceptive Pill Checklist Care Plan HTML"},"content":[{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

Please complete these questions before your appointment.

","type":"text"}]},{"type":"paragraph","content":[{"text":"

To complete this form, please click the 'Edit plan' button in the top right of the page.

","type":"text"}]},{"type":"paragraph","content":[{"text":"

When you have answered all the questions, please click 'Save' in the bottom right of the page.

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"1. Are you currently using any kind of hormonal contraception?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes:

","type":"text"}]},{"type":"paragraph","content":[{"text":"What is your current contraceptive? ","type":"text"}]},{"type":"paragraph","content":[{"text":"Would you like to change to another contraceptive? Please say why:","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If no:

","type":"text"}]},{"type":"paragraph","content":[{"text":"Have you used hormonal contraceptives in the past? Please specify any you have used: ","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"2. Do you know the pill you would like to order?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Combined pill","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Progestogen only pill","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Don't know","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"3. Have you had your blood pressure measured in the last 12 months?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes (if known, please enter reading and date at the top of this form)","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"4. Are you allergic to any medications or substances?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes, please specify below:

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Penicillin","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Peanuts or soya","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Lactose","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Other medications: ","type":"text"}]},{"type":"paragraph","content":[{"text":" Other substances: ","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"5. Do you smoke?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"6. Are you pregnant or have you given birth in the last 6 weeks?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" I am pregnant or there is a chance I could be","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" I gave birth in the last 3 weeks","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" I gave birth in the last 3-6 weeks","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" None of the above","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If you have given birth in the last 3-6 weeks:

","type":"text"}]},{"type":"paragraph","content":[{"text":"Are you breastfeeding?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"Did you have:","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Blood transfusion or significant blood loss","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Caesarian section","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Pre-eclampsia during or after pregnancy","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" None of the above","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"7. Have you been diagnosed with high blood pressure?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes:

","type":"text"}]},{"type":"paragraph","content":[{"text":"Was it related to:","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Pregnancy","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" White coat syndrome","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Other","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"8. Have you ever had a heart attack or stroke?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes:

","type":"text"}]},{"type":"paragraph","content":[{"text":"Please give details of what happened, when, and the treatment you had: ","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"9. Have you had a blood clot before?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes:

","type":"text"}]},{"type":"paragraph","content":[{"text":"Please provide details: ","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"10. Has someone in your close family had a blood clot?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes:

","type":"text"}]},{"type":"paragraph","content":[{"text":"What relation were they to you? ","type":"text"}]},{"type":"paragraph","content":[{"text":"How old were they?:","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" 45 years old or over","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Less than 45 years old","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"11. Have you had major surgery in the last 3 weeks?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes:

","type":"text"}]},{"type":"paragraph","content":[{"text":"Please provide details: ","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"12. Do you have diabetes?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes:

","type":"text"}]},{"type":"paragraph","content":[{"text":"Please provide details: ","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"13. Do you have any conditions affecting your liver or kidneys?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes:

","type":"text"}]},{"type":"paragraph","content":[{"text":"Please provide details: ","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"14. Have you ever had any of the following cancers? (select all that apply)","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Breast cancer","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Cervical cancer","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Liver cancer","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Other cancers","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Never had cancers","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"15. Do you ever have unexpected or unusual vaginal bleeding?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes:

","type":"text"}]},{"type":"paragraph","content":[{"text":"How long have you had it? When did it happen last? ","type":"text"}]},{"type":"paragraph","content":[{"text":"Select all that apply:","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Bleeding during or after sexual intercourse","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Heavy bleeding","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Very painful bleeding","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" None of the above","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"16. Have you had a STI test in the last 12 months or since your last new sexual partner?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes:

","type":"text"}]},{"type":"paragraph","content":[{"text":"What were the results? ","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If no:

","type":"text"}]},{"type":"paragraph","content":[{"text":"

Please consider ordering a full STI screen through ","type":"text"},{"type":"inlineCard","attrs":{"url":"http://www.friskywales.org"}},{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

17. If you are 25 years or older:

","type":"text"}]},{"type":"paragraph","content":[{"text":"When was your last cervical smear? ","type":"text"}]},{"type":"paragraph","content":[{"text":"What was the smear result? ","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"18. Do you have any other medical conditions?","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes:

","type":"text"}]},{"type":"paragraph","content":[{"text":"Please provide details: ","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"19. Are you taking any medications currently or have recently finished a course of medication? (including over the counter medications)","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" Yes","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":" No","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

If yes:

","type":"text"}]},{"type":"paragraph","content":[{"text":"Please provide medication name, dose and what it was used for: ","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]},{"type":"paragraph","content":[{"text":"

","type":"text"}]}]},{"type":"paragraph"}],"version":1}

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