Contraceptive Pill Review

Have you been asked by the practice to complete this online review? *

Yes

No

Please do not fill this form in until you have been asked to complete it by the GP surgery. If you have not been asked to submit this form, you will need to discuss it with the surgery first.

About You

Height (in Metres): *

eg. 1.75

Weight (in Kilograms): *

eg. 60.6

BMI

Please note: BMI calculator is only for patients aged 18 and over.

Blood Pressure:

In format: Systolic "Higher" / Diastolic "Lower"

Do you smoke?

Current smoker

Ex-smoker

Never smoked

Would you like to arrange an appointment for smoking cessation?

Yes

No

Contraception Pill Review

Do you regularly check your breasts?

Yes

No

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

Do you suffer from severe headaches or migraines?

Yes - But the Doctor is unaware

Yes - But the Doctor is aware

No

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

Are you experiencing any irregular bleeding?

Yes

No

Please book an appointment to see the practice nurse

What was the first day of your last menstrual period?

Have you ever had a Stroke/Blood Clot/Heart Attack or any Heart Problems?

Have any of your family members had a Stroke/Blood Clot/Heart Attack or any Heart Problems?

Do you have any family history of womb (Uterus) or Breast Cancer?

Would you like information about long acting reversible contraception (Contraceptive implant, injections, coils)?

Do you have any problems remembering to take your pill?

Do you take any other non-prescribed medication?

Do you know the effect of your pill working if you miss a pill or have sickness and diarrhoea?

Please add any further comments:

*

I confirm that the information provided is accurate to the best of my knowledge

Please tick box to consent to receive a SMS response from the nurse (if required).

Tell us whether you accept cookies