IUD Insertion Discharge Assessment Form
Please complete this assessment to ensure safe discharge following your IUD insertion.
Date of IUD Insertion
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient's current pain level
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Amount of vaginal bleeding observed
*
None
Spotting
Light
Moderate
Heavy
Signs or symptoms present (select all that apply)
*
Dizziness
Nausea
Abdominal pain/cramping
Fever or chills
None of the above
Other
Patient has been instructed on post-procedure care
*
Yes
No
Patient is aware of warning signs requiring immediate attention
*
Yes
No
Patient's understanding of when to schedule follow-up visit
*
Understands clearly
Needs further explanation
Any complications during or after the procedure?
*
No complications
Expulsion
Perforation
Vasovagal reaction
Other
Additional comments or observations
Name or initials of clinician completing assessment
*
Submit Assessment
Should be Empty: