Contraceptive Pill Review

If you are on a combined contraceptive pill or patch it is essential to provide a weight, height and blood pressure reading please

Last Updated: 17/10/2023

  • Your Details

  • Ethnicity

    Ethnic Group

  • Contraceptive Pill Review

    Are you aged 35 & over, or will be within the next 12 months?
    Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with a DVT, PE, Stroke/cerebro-vascular disease, heart disease or known family history of any BRCA gene
    Have you been diagnosed with or experienced any of the following conditions; unexplained leg swelling, chest pain, heart disease, high blood pressure, diabetes, liver disease, gallbladder disease, epilepsy, breast cancer, systemic lupus erythematosus (SLE), known clotting disorder or stroke/TIA
    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
    Are you currently taking any of the following medications; anti-epileptic medication, Rifampacin, St Johns Wort, a blood thinner
    Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months
    Have you forgotten to take your pill on more than one occasion per month
    Do you know what to do if you miss a pill that is due
    Would you like to discuss long acting reversible contraception options with you GP or practice nurse
    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.
This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.