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 DETAILSName* First Last Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneEmail* CONTRACEPTIVE PILL REVIEWWill you be 35 years or older within the next 12 months?* Yes No Weight* Smoking Status* Smoker Ex-Smoker Non-Smoker 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?* Deep vein thrombosis (a blood clot in the veins of the leg) Pulmonary embolism (a blood clot in the lungs) Stroke or cerebro-vascular disease Heart disease Have you been diagnosed with or experienced any of the following conditions in the past 12 months?* Unexplained leg swelling Chest pain that is worse when breathing deeply or unexplained shortness of breath High blood pressure High cholesterol Diabetes Liver disease Gallbladder disease including gallstones Epilepsy Raynaud's disease Breast cancer Are you currently taking any of the following medications?* Anti-epileptic medication Rifampacin St Johns Wort 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?* Yes No Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months?* Yes No Have you forgotten to take your pill on more than one occasion per month?* Yes No Would you like to discuss 'what to do in the event of a missed pill' with you GP or practice nurse?* Yes No Would you like to discuss long acting reversible contraception options with you GP or practice nurse?* Yes No Consent*This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. * I consent to the practice collecting and storing my data from this form.CAPTCHA
