Contraceptive Pill Review Form

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

Last Updated: 04/11/2020

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Contraceptive Pill Review

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

Will you be 35 years or older within the next 12 months? *

Yes No

Weight

Smoking Status *

Current smoker

Ex-Smoker

Non-Smoker

If you currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

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?

Deep vein thrombosis (a blood clot in the veins of the leg)

Pulmonary embolism (a blood clot in the lungs)

Stroke or cerebro-vascular disease

Heart disease

Have you been diagnosed with or experienced any of the following conditions in the past 12 months?

Unexplained leg swelling

Chest pain that is worse when breathing deeply or unexplained shortness of breath

High blood pressure

High cholesterol

Diabetes

Liver disease

Gallbladder disease including gallstones

Epilepsy

Raynaud's disease

Breast cancer

Are you currently taking any of the following medications?

Anti-epileptic medication

Rifampacin

St Johns Wort

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? * *

Yes No

Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? * *

Yes No

Have you forgotten to take your pill on more than one occasion per month? *

Yes No

Would you like to discuss 'what to do in the event of a missed pill' with you GP or practice nurse? *

Yes No

Would you like to discuss long acting reversible contraception options with you GP or practice nurse? *

Yes No

Blood Pressure Reading

Please provide an up to date blood pressure reading

Date of reading *

Systolic Blood Pressure (Sys) *

Diastolic blood Pressure (Dia) *

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Contraceptive Pill Review Form

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