Contraceptive Pill Review

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

Contraceptive Pill Review

Contraceptive Pill Review

About You

In Metres
In KG
Systolic "Higher" / Diastolic "Lower" / Heart Rate
Smoking Status: *

Contraception Pill Review

Have you ever had a Deep Vein Thrombosis/Pulmonary embolism? *
Is there a family history of Deep Vein Thrombosis/Pulmonary embolism or Breast Cancer? *
Do you regularly check your breasts? *

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

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.

Are you experiencing any irregular bleeding? *

Please book an appointment to see the practice nurse

Have you received any new medication since your last prescription? *
Have you considered long term contraception? *
*