Contraceptive Pill Review 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 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.

Has there been any recent change to medical history that we need to be aware of? *

Yes No

Smoking Status *

Smoker

Ex-Smoker

Non-Smoker

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, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months?

Blood Clot

Breast Cancer

Have you experienced any issues / adverse effects from takin the pill such as unscheduled bleeding? *

Yes No

Are you up to date with your smear test?

Yes No

Are you aware of how to take you pill? *

Yes No

Are you interested in switching to alternative "long acting" contraception such as the coil, the implant or depo-injection? *

Yes No

Weight / Height

Please enter your blood pressure

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.

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Contraceptive Pill Review Form

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