PocketGuide: Client Assessment - Checklists: Hormonal Methods and IUD

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PocketGuide for Family Planning Service Providers

Client Assessment

Checklists: Hormonal Methods and IUD

Hormonal Methods Checklist | IUD Checklist

Table 1. Hormonal Methods Checklist (pills, injectables and implants)

	YES	NO
Breastfeeding baby less than 6 weeks old^a,b
Bleeding/spotting between periods or after intercourse
Jaundice (abnormal yellow skin or eyes)
Smoker over age 35^b
Diabetes
Severe headaches or blurred vision
Severe pain in calves, thighs or chest, or swollen legs (edema)^b
High blood pressure (history of)^b
Heart attack, stroke or heart disease (history of)
Breast cancer or suspicious (firm, nontender or fixed) lump in the breast
Taking drugs for epilepsy (phenytoin and barbiturates) or tuberculosis (rifampin)^c

^a Combined estrogen/progestin contraceptives (COCs and CICs) are the methods of last choice for breastfeeding women, especially in the first 6–8 weeks postpartum.
^b Does not apply to progestin-only contraceptives (implants, PICs and POPs).
^c Does not apply to PICs.

Table 2. IUD Checklist

	YES	NO
Client (or partner) has other sex partners
Sexually transmitted genital tract infection (GTI) or other STD (e.g., HBV, HIV/AIDS) within the last 3 months
Pelvic infection (PID) or ectopic pregnancy (within the last 3 months)
Heavy menstrual bleeding (twice as long or twice as much as normal)^a
Prolonged menstrual bleeding (> 8 days)^a
Severe menstrual cramping (dysmenorrhea) requiring analgesics and/or bed rest^a
Bleeding/spotting between periods or after intercourse
Symptomatic valvular heart disease^b

^{a Does not apply to progestin-releasing
IUDs.

^b Give prophylactic antibiotics if not on long-term
antibiotics at the time of IUD insertion. (See IUDs
chapter for additional information.)

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Last Updated: 09 Jul 2003

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