Contraceptive Pill Review

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

Contraceptive Pill Review

Contraceptive Pill Review

Section

About You

eg. 1.75
eg. 60.6
Smoking Status: *
Do you drink alcohol? *

Blood Pressure

Contraception Pill Review

If over 25 have you had a smear test in the last three years? *
Do you have any bleeding between your periods? *
Do you have any bleeding after sex? *
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.

Have you ever had a stroke, a blood clot in your lungs or legs, a heart attack or any heart problems? *
Have your mother, father, brother or sister had a had a blood clot in their lungs or legs aged under 60? *
Have your mother, father, brother or sister had a heart attack or any heart problems aged under 60? *
Have you, or anyone in your family, had cancer of the breast? *
Do you regularly check your breasts?

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

Do you have problems forgetting to take your pill? *
Have you, or any family member, had womb or cervical cancer? *
Have you been given information about long acting reversible contraceptives (Implants, Coils or Injections)? *

If you would like more information please see www.fpa.org.uk or book to discuss these options with our pharmacist or a doctor.

Please confirm you have read and understood the following: *
*
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