Contraceptive Pill Review Form

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

"*" indicates required fields

YOUR DETAILS

Name*
Date of Birth*

CONTRACEPTIVE PILL REVIEW

Will you be 35 years or older within the next 12 months?*
Smoking Status*
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?*
Are you currently taking any of the following medications?*
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?*
Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months?*
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 you GP or practice nurse?*
Would you like to discuss long acting reversible contraception options with you GP or practice nurse?*
Consent*