General Practitioner Template

Contraception Counselling

A professional General Practitioner template for healthcare professionals.

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Specialty

General Practitioner

Used

460 times

Type

Note

Last edited

05/08/2026

Created by

Kieran Dang

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About this template

This Contraception Counselling template is designed for General Practitioners and nurses to document detailed patient interactions regarding contraceptive options. It includes sections for medical history, gynaecological history, family history, lifestyle factors, and patient preferences. The template also covers various contraceptive methods such as hormonal contraceptives, barrier methods, IUDs, permanent methods, and emergency contraception. This comprehensive template ensures that all relevant information is captured, facilitating informed decision-making and personalized patient care. Ideal for use in primary care settings, this template helps streamline the documentation process, making it efficient and thorough.

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Patient Name: Jane Doe Date of Birth: 01/01/1990 Date of Visit: 10/10/2023 Medical Record Number: 123456 Visit Type: Contraception Counselling History and Background: Presenting Complaint: Seeking advice on long-term contraception options. Medical History: - Chronic Conditions: None - Previous Contraceptive Methods Used: Hormonal pills (experienced nausea), Condoms (no issues) - Allergies: None - Medications: Multivitamin daily Gynaecological History: - Menstrual History: Regular cycles, no abnormalities - Sexual Activity: Active, monogamous relationship - Pregnancy History: 1 pregnancy, full-term, no complications Family History: - Reproductive Health: No known issues - Chronic Diseases: Mother has hypertension Lifestyle Factors: - Smoking Status: Non-smoker - Alcohol Use: Social drinker - Physical Activity: Regular exercise Patient’s Preferences and Concerns: Prefers a long-term, low-maintenance contraceptive method. Contraceptive Options Discussed: 1. Hormonal Contraceptives: - Birth Control Pills: Discussed effectiveness, side effects, and need for daily adherence - Contraceptive Patch: Discussed application, effectiveness, and possible skin reactions - Depo-Provera Injection: Discussed frequency of injections, side effects 2. Barrier Methods: - Condoms: Discussed use, effectiveness, and additional benefits like STI prevention 3. Intrauterine Devices (IUDs): - Copper IUD: Discussed non-hormonal, long-term use, possible menstrual changes - Hormonal IUD: Discussed hormonal effects, duration, and potential side effects 4. Permanent Methods: - Sterilization: Discussed permanency, procedure details, and consideration for future fertility 5. Emergency Contraception: - Options Available: Discussed when to use, effectiveness, and accessibility Advice Given: - Method Selection: Patient interested in Hormonal IUD - Usage Instructions: Provided detailed instructions on IUD usage - Follow-Up: Scheduled follow-up in 3 months to assess satisfaction and any side effects - Emergency Contraception: Provided information on emergency contraceptive options in case of contraceptive failure or unprotected intercourse. Patient Education Materials Provided: Brochure on Hormonal IUDs Signature: Dr. Thomas Kelly General Practitioner 555-123-4567 Date: 10/10/2023