Contraceptive Pill Review

You will need an up to date blood pressure reading before you complete the online details. This can easily be organised using a home monitoring machine or through local pharmacies. Please record this before you complete this form.

If you are taking the combined oral contraceptive pill there is a slightly higher risk of developing breast cancer, cervical cancer, having a heart attack or stroke and developing a blood clot in the leg or lung. If you were not aware of this and wish to discuss further please arrange an appointment with a GP.

Contraceptive Pill Review

Name

First Last

Date of birth

DD slash MM slash YYYY

Preferred contact telephone number

Email Optional

Height, Weight and Blood Pressure

Height (ft in)

Weight (st lbs)

Your blood pressure reading

e.g. 120/70

Pill Review

Name of requested contraceptive pill

Have you had any problems or concerns with the pill?

Yes

Do you smoke?

Yes

Do you suffer from migraines?

Yes

Do you have a family or personal history of DVT or pulmonary embolism?

Yes

Have you ever had heart disease, stroke, cancer, or major illness?

Yes (please list in the comment box below)

Do you understand the risks and benefits of your current contraceptive pill?

Yes

Have you had any irregular bleeding such as between periods or after sex?

Yes

Have you considered the coil or implant?

Yes

Any comments you would like to add? Optional

Privacy Notice

I consent to the practice collecting and storing my data on this form

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. Please read our Privacy Notice for details of how we protect and manage submitted data.

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Please note the Practice will be closed every Thursday between 1pm-2pm for staff training.

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