Contraceptive Pill Review

If you have been advised by the surgery to submit a contraceptive pill review please use this form.

Contraceptive Pill Review

Contraceptive Pill Review

About You

Please use this date format: DD/MM/YYYY.

Blood Pressure & Weight

If you do not have access to a blood pressure monitor or weighing scales, please ask to use them at reception.

Your health

Please answer all the questions in this section.
Will you be 35 years or older within the next 12 months? *
Do you smoke? *
Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months?
Have you been diagnosed with or experienced any of the following conditions in the past 12 months?
Are you currently taking any of the following medications?
Do you suffer from migraines with aura, or a headache associated with weakness or numbness on one side of your face or body, or difficulty with speech? *
A migraine is usually a severe headache felt as a throbbing pain at the front or on one side of the head. Some people experience a sensation, or aura, just before their migraine starts. Symptoms of aura include flashes of light or blind spots, difficulty focusing, and seeing things as if you are looking through a broken mirror. This is known as migraine with aura.
Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? *
Have you forgotten to take your pill on more than one occasion per month? *
Would you like to discuss 'what to do in the event of a missed pill' with you GP or practice nurse? *
Would you like to discuss long acting reversible contraception options with you GP or practice nurse? (Please see link on attached information sheet) *
Do you have any questions regarding your contraception or this questionnaire? *

Patient Declaration

I confirm that all of the information that I have provided on this form is correct at the time of completing the form.

I confirm that I will inform my GP should there be any changes to my health whilst I am taking oral contraceptive tablets.

Please note that the details you give will be used to update your medical records. If your correct contact information is not entered we will not be able to respond to you.

*
Sending