Contracteptive 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.

Weight (in kg)

What is your height?

Smoking Status *

Smoker

Ex-Smoker

Non-Smoker

if Yes- how many do you smoke per day?

Would you like help giving up?

Have you had your blood pressure checked in the last 12 months? If you don't have access to a blood pressure machine then you will need to make an appointment with one of the nurses.. *

What is the name of you current contraceptive pill? *

How do you take your contraceptive pill? e.g back to back, 4 day break etc? *

Are you aware how the pill works?

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

Did you know that the contraceptive pill may not work if you have diarrhoea or vomiting or are on antibiotics?

Yes No

Are you aware that the contraceptive pill does not protect you from sexually transmitted infections, so you will need a condom as well to protect yourself

Yes No

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

Yes No

Do you take any over the counter medicines (vitamins, supplements etc) *

Yes No

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?

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

Do you or anyone in your family have known blood clotting illnesses or abnormalities?

Yes No

Do you have parents or siblings who have had any clots in their arms, legs or lungs under the age of 45?

Yes No

Do you understand the symptoms of blood clotting can include shortness of breath, sharp chest pain, coughing up blood, calf pain and swelling? *

Yes No

Do you know the risk of a clot increases with the combined pill if you travel for extended periods? E.g. long-haul-flight *

Yes No

Do you understand that you should tell a healthcare professional that you are on the pill if you need to have an operation or have a prolonged period of immobilisation e.g. leg in plaster?

Yes No

Do you have any parents or siblings who have had heart disease or strokes under the age of 45?

Yes No

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

Yes No

Do you have any personal [yourself] or family history of breast cancer under the age of 50?

Are you breastfeeding?

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.

Riverside Surgery Contraceptive Pill Review Form

Further Information

Cookies on the Riverside Surgery website

Riverside Surgery Contraceptive Pill Review Form

Further Information

Connect With Us