Contraceptive Pill Review

Form only to be completed if requested by the practice.

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

In Metres
In KG

Smoking Status

Do you, or have you ever, smoked? *
Would you like advice on how to stop smoking? *

Blood Pressure

We need a blood pressure reading within the past 12 months to continue issuing your contraception safely

Contraception Pill Review

Do you regularly check your breasts? *

Please ask reception for our information regarding the importance of regular breast self-examination.

Do you suffer from headaches or migraines? *
Does the headache cause loss of vision? *

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Do you experience any visual disturbance or pins and needles (or altered sensation) to one side of the face or body? *
Do you have a personal history or first degree family history of blood clots eg. DVT (Deep Vein Thrombosis) or PE (Pulmonary Embolism? *
Are you experiencing any irregular bleeding? *

Please book an appointment to see the practice nurse

*