Contraceptive Pill Review

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

Contraceptive Pill Review

About You

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..

Have you missed any pills, or do you think you might be pregnant? *
Do you have any specific questions or concerns about your contraception? *
In Metres
Which type of contraceptive pill do you take? *
Are you taking Roaccutane (isotretinoin)? *
Have you used emergency contraception in the last year? *
Do you have any concerns about or side effects with your contraception? *
Do you know what to do if you miss a pill? *

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? *

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.

Are you experiencing any irregular vaginal bleeding?
Have you ever had an abnormal smear test? *
Do you have any abnormal vaginal discharge? *
Have you had a sexual health check in the last 12 months? *

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

Do you suffer from severe headaches or migraines?

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

Do you smoke? *
Do you smoke 15 cigarettes or more a day? *
Please select which best describes your smoking status: *
Are you being treated for high blood pressure? *
Have you ever had high cholesterol? *
Have you ever had any heart problems (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)? *
Have you ever had a blood clot? *
Do you have parents or siblings who have ever had a blood clot (For example, a pulmonary embolism (PE) or deep vein thrombosis (DVT)?
Have you ever had cancer? *
Were any of your parents or siblings diagnosed with breast cancer under the age of 50? *
Do you have a blood clotting disorder? *
Do you have diabetes? *
Have you ever been told you have high blood sugar? *
Do you suffer from epilepsy? *
Have you ever had liver or gallbladder problems? *
Have you had weight loss surgery? *
Have you had any major surgery in the past 12 weeks? *
Do you have any significant surgery planned? *
Since you last had the contraceptive pill prescribed, have you become less mobile (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? *
Do you use any recreational (party) drugs? *
Are you having appointments with a hospital doctor (specialist) in an outpatient clinic? *
Are you taking any drugs or medicines that your practice doesn't know about (This includes any herbal remedies or over the counter medicines such as St John's Wort)? *
Do you have any allergies (For example, medications, creams or food, including nut and soya bean oils)? *
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? *
Do you regularly check your breasts?

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

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

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