Contraceptive Review

For women 18 years and older, who are currently taking a contraceptive pill, prescribed by Shepperton Medical Practice who are happy with their current contraception and wish to continue taking it.

In order to provide the contraceptive pill safely we need to ask you a number of questions. We would be grateful if you could complete this form when you submit your annual repeat prescription request.

If you are having any problems with your medication or would like to consider alternative contraception options, please speak to Nurse Lynn, or your GP, who will be able to offer advice.

Contraceptive Pill Review

Contraceptive Pill Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please make sure you have had your blood pressure and weight taken within the last 4 weeks. You can have this done at the pharmacy if you do not have the facilitates at home to do this.

Contraceptive Review

Are you happy with your current method of contraception? *
Are you aware of the alternatives such as long acting reversible contraceptives? *
Are you a smoker? *
Are you a smoker over the age of 35? *
Would you like help giving up? *
Is your BMI less than 35? *
Is your blood pressure more than 140/90mmHg? *
Do you knowingly have a q-risk >10 or a past history of heart disease, stroke, TIA or arterial disease? *
Have you or any family member, had a deep vein thrombosis or pulmonary embolus (blood clot inthe leg or lung), under the age of 45? *
Are you currently immobile? *
Do you suffer from migraines? *
Do you suffer from visual symptoms prior to the migraine headache? *
Do you have a current history or past history of breast cancer? *
Do you have uncontrolled diabetes? *
Have you developed any new symptoms or bleeding patterns since your last review? *
Have you had any changes to your medical / family / drug history since your last review? *
Are you aware of how the pill works? *
Are you aware of what to do if you miss a pill? *
You can find out more information on the FPA or BMG websites.
Are you aware that the contraception may not work if you have diarrhoea or vomiting? *
Are you aware that the contraceptive pill doesn't protect you from Sexually Transmitted Infection? *
Would you like to book a consultation with a health care professional to discuss or arrange fitting a long acting reversible contraceptive? *
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