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
Systolic Blood Pressure/ Diastolic Blood Pressure
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?