Contraceptive Pill Review

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

If you are under 16 years of age we will always follow up submission of this form with a telephone call, please ensure the number you would like to be called on is added to this form. If you would prefer not to receive the call please phone the practice to arrange a planned telephone appointment with one of our practice nursing team.

Further Information:

Contraceptive Pill Review - Westgate

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.

If you do not have access to a home blood pressure device, please visit the practice and use the machine in our waiting area and then submit this form.

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 have a family history of BRCA gene?
Do you have a personal history of antiphospholipid syndrome or have you ever been tested for this condition?
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.

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

Are you currently taking any of the following medications?
Do you smoke?
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.

E.g. Monday AM/PM, Tuesday AM/PM
Please upload any relevant evidence in relation to this request.
Maximum upload size: 67.11MB