Contraceptive Pill Review Form

The next few questions will help your clinician decide whether it is safe for you to continue with your contraception. Please be as accurate as possible. If you need emergency contraception please contact your local pharmacy or NHS 111. *

I Understand

Have you missed any pills, or do you think you might be pregnant? *

Do you have any specific questions or concerns about your contraception? If yes, please provide details. *

Will you be 35 years or older within the next 12 months? *

Yes No

Weight

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

Are you currently taking any of the following medications?

Anti-epileptic medication

Rifampacin

St Johns Wort

Are you taking Roaccutane (isotretinoin)?

Yes No

Do you know your blood pressure reading from the last month?

Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? * *

Yes No

Why are you taking contraception? *

Do you have any concerns about or side effects with your contraception?

Would you like to discuss 'what to do in the event of a missed pill' with you GP or practice nurse? *

Yes No

Have you forgotten to take your pill on more than one occasion per month? *

Yes No

Do you know what to do if you miss a pill? *

Yes No

Would you like to discuss long acting reversible contraception options with you GP or practice nurse? *

Yes No

Do you know what to do if you have diarrhoea or vomiting while taking the contraceptive pill? *

Yes No

Which type of contraceptive pill do you take?

What is the name of your contraceptive pill? *

Have you used emergency contraception in the last year? *

Yes No

Have you had any unexpected vaginal bleeding? *

Yes No

When was your last smear test (cervical screening)?

Have you ever had an abnormal smear test? *

Do you have any abnormal vaginal discharge?

Have you had a sexual health check in the last 12 months?

Yes No

Are you breastfeeding? *

Yes No

Do you ever get headaches? *

Yes No

Do you get migranes? *

Yes No

Smoking Status *

Smoker

Ex-Smoker

Non-Smoker

Are you being treated for high blood pressure? *

Yes No

Have you ever had high cholesterol? *

Yes No

Have you ever had heart problems?

Yes No

Have you ever had a stroke or a mini-stroke (TIA)? *

Yes No

Have you had a blood clot? *

Yes No

Do you have parents or siblings who have ever had a blood clot?

Have you ever had cancer?

Do you have any breast symptoms that weren't there before?

Were any of your parents or siblings diagnosed with breast cancer under the age of 50?

Do you have a blood clotting disorder?

Do you have diabetes?

Yes - Type 1

Yes - Type 2

No

Have you ever been told you have high blood sugar?

Yes No

Have you ever had liver or gallbladder problems?

Yes No

Have you had weight loss surgery? *

Yes No

Have you had any major surgery in the past 12 weeks? *

Yes No

Since you last had the contraceptive pill prescribed, have you become less mobile? *

Yes No

Do you feel at risk of violence?

Are you having appointments with a hospital doctor (specialist) in an outpatient clinic?

Has a medical professional (like a doctor or nurse) ever told you that you cannot take some form of contraception? For example, combined oral contraceptive pill, contraceptive patch or contraceptive ring. Please provide details. *

Is there anything else you would like to tell us that we have not asked?

Are you taking any drugs or medicines that the Witterings Medical Centre doesn't know about? *

How many units of alcohol do you drink each week? (1 pint of beer is approximately two units and one small glass of wine is 1 unit)

Do you have any allergies?

Are you, or is there a chance you might be pregnant?

Yes No

Have you given birth in the last 12 weeks?

Yes No

Have you had a miscarriage in the last 12 weeks?

Yes No

Have you had a termination in the last 12 weeks?

Yes No

Have you or anyone in your household had COVID in the last 3 months? Or are you self isolating right now? *

Yes No

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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