Contraceptive Pill Review

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

Further Information:

Contraceptive Pill Review

Contraceptive Pill Review

Have you received a letter, text message or verbal invitation to complete this assessment?

Your Health

Unit of measurement: *
Unit of measurement: *

Please provide your most recent blood pressure reading if possible

Please use this date format: DD/MM/YYYY.
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Contraceptive Pill Review

Will you be 35 years or older within the next 12 months? *
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?
Have you been diagnosed with or experienced any of the following conditions in the past 12 months?
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? *
A migraine is usually a severe headache felt as a throbbing pain at the front or on one side of the head. Some people experience a sensation, or aura, just before their migraine starts. Symptoms of aura include flashes of light or blind spots, difficulty focusing, and seeing things as if you are looking through a broken mirror. This is known as migraine with aura.
Are you currently taking any of the following medications?

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

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

Please book an appointment to see the practice nurse

Have you forgotten to take your pill on more than one occasion per month? *
Would you like to discuss 'what to do in the event of a missed pill' with your GP or practice nurse? *
Would you like to discuss long acting reversible contraception options with your GP or practice nurse? *
Do you have any questions regarding your contraception or this questionnaire? *

Patient Declaration

Please note that the details you give will be used to update your medical records. If your correct contact information is not entered we will not be able to respond to you.