Contraceptive Pill Review

Annual Contraceptive “Pill” Check

Please complete the form which will be reviewed by our Women’s Health Nurse or GP. If everything is OK we’ll issue your prescription and send you a text to confirm. If further information is required we’ll contact you to arrange a telephone consultation (normally).

Blood Pressure Check

Mini Pill – A Blood Pressure Check is not Required

Combined Pill – Please obtain a blood pressure reading and enter the results onto the form. During the COVID-19 outbreak you will need to obtain a BP machine from your local Phamacy, which are quite cheap to purchase, as you are not permitted into the surgery to use our self-service machine.

Contraceptive Pill Review

If you are human, leave this field blank.

Patient Details

Please enter your Blood Pressure reading taken from your own Blood Pressure machine if you have one.

Full Name: *

Please use the name on your patient records

Date of Birth: *

Please use date format DD/MM/YYYY

Email Address: *

All correspondence will go to this address.

Contact Number:

Postcode:

Address:

Please enter your Blood Pressure reading taken from your own Blood Pressure machine if you have one.

This should be the same day you submit this form.

Date Blood Pressure reading taken:

Heart Rate:

Systolic "Higher”

Diastolic “Lower”

Have you missed any pills, or do you think you might be pregnant? *

Yes, I have missed a pill, or I think I might be pregnant

No, I haven't missed any pills, and I am not pregnant

Not sure

Do you have any specific questions or concerns about your contraception?

Yes

Please tell us what questions or concerns you have about your contraception.

Please tell us your weight:

Please use Kilograms (KG).

Please tell us your height:

Please use centimetres (CM)

Why are you taking contraception? *

Which type of contraceptive pill do you take? *

Combined hormonal contraceptive pill (2 hormones)

Progesterone-only pill (mini-pill)

Don't know

What is the name of your contraceptive pill? *

Are you taking Roaccutane (isotretinoin)? *

Yes

Have you used emergency contraception in the last year? *

Yes

Do you have any concerns about or side effects with your contraception? *

Yes

Please tell us what concerns or side effects you have about the contraceptive pill. *

Do you know what to do if you miss a pill? *

Yes

For more information, please refer to the email we will send you about your contraceptive pill or the information leaflet that comes with your pill.

Do you know what to do if you have diarrhoea or vomiting while taking the contraceptive pill? *

Yes

For more information, please refer to the email we will send you about your contraceptive pill or the information leaflet that comes with your pill.

Have you had any unexpected vaginal bleeding? *

Yes

When was your last smear test (cervical screening)? *

Please use format DD/MM/YYYY

Have you ever had an abnormal smear test? *

Yes

Please tell us when you had an abnormal smear test and what the results were: *

Do you have any abnormal vaginal discharge?

Yes

Please tell us more about the abnormal vaginal discharge: *

Have you had a sexual health check in the last 12 months? *

Yes

You should have a sexual health check when you start having sex with a new partner.

Do you ever get headaches? *

Yes

Do you get migraines? *

Yes

Do you smoke? *

Yes

Do you smoke 15 cigarettes or more a day? *

Yes

Please select which best describes your smoking status: *

I have never smoked

I gave up less than 1 year ago

I gave up more than 1 year ago

Are you being treated for high blood pressure? *

Yes

Have you ever had high cholesterol? *

Yes

Have you ever had any heart problems? *

Yes

For example, heart attack, angina, chest pain on exertion, abnormal heart rhythm, valve problem or a problem with your heart since birth.

Have you ever had a stroke or a mini-stroke (TIA)? *

Yes

Have you ever had a blood clot? *

Yes

Please tell us when you had a blood clot and what happened. *

Do you have parents or siblings who have ever had a blood clot? *

Yes

Don't Know

For example, a pulmonary embolism (PE) or deep vein thrombosis (DVT).

Have you ever had cancer? *

Yes

What type of cancer did you have? *

Do you have any breast symptoms that weren't there before? *

Yes

For example, a breast lump, skin changes or nipple discharge.

Were any of your parents or siblings diagnosed with breast cancer under the age of 50? *

Yes

Do you have a blood clotting disorder? *

Yes

Which blood clotting disorder do you have? *

Do you have diabetes? *

Yes

Have you ever been told you have high blood sugar? *

Yes

Do you suffer from epilepsy? *

Yes

Are you on medication to help with this? *

Yes

Have you ever had liver or gallbladder problems? *

Yes

Have you had weight loss surgery? *

Yes

Have you had any major surgery in the past 12 weeks? *

Yes

Do you have any significant surgery planned? *

Yes

What surgery do you have planned and when is this likely to happen? *

Since you last had the contraceptive pill prescribed, have you become less mobile? *

Yes

For example, have you been bed-bound, used a wheelchair or broken a leg? This may increase your risk of blood clots and stroke.

Do you feel at risk of violence? *

Yes

Please tell us why you feel you are at risk of violence: *

Do you use any recreational (party) drugs? *

Yes

Please tell us what recreational (party) drugs you take: *

Are you having appointments with a hospital doctor (specialist) in an outpatient clinic? *

Yes

Please tell us which type of hospital doctor (specialist) you have been seeing in an outpatient clinic and how long you have been under their care: *

Are you taking any drugs or medicines that your practice doesn't know about? *

Yes

This includes any herbal remedies or over the counter medicines such as St John's Wort

Please tell us what other drugs or medicines you are taking: *

Do you have any allergies? *

Yes

For example, medications, creams or food (this includes nut and soya bean oils)

Please tell us what you are allergic to: *

How many units of alcohol do you drink each week? *

(1 pint of beer is approximately two units and one small glass of wine is 1 unit)

Has a medical professional (like a doctor or nurse) ever told you that you cannot take some form of contraception?

Yes

When did a medical professional (like a doctor or nurse) tell you that you cannot take a certain form(s) of contraception and what was the reason (if known)?

Is there anything else you would like to tell us that we have not asked? *

Yes

What else would you like to tell us?

Nominate a Pharmacy

My chosen Pharmacy is:

Other

Pharmacy Name: *

Pharmacy Address: *

Pharmacy Postcode: *

For your safety, we will email you information about your contraceptive pill. It is important that you read this.

We are currently CLOSED.

Flu and COVID-19 jabs

Our Campaigns

Walk-in Blood Tests - Every weekday from 8am to 10am

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Patient Details

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We are currently CLOSED.

Flu and COVID-19 jabs

Our Campaigns

Walk-in Blood Tests - Every weekday from 8am to 10am

NHS Health Checks

You have a question?

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