Form: Contraceptive Pill Review

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In order to provide another prescription of your contraceptive pill we need to ask you a number of questions.

This form is not to be used if you have not started the contraceptive pill already or have recently had a break from your usual pill.
If you are having problems with your contraceptive pill or would like to switch to a different pill or other method of contraception, please do not use this form and book an appointment to see one of our nurses.
This form is only to be used by women aged 16 years or older.

Please fill out the following information:

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Personal Details

If you have been advised by the surgery to submit a contraceptive pill review please use this form.

Please double check you've entered the correct email address

May be used to identify you

Contraception Pill Review

ie: to manage periods, contraception only or both.

Your Recent Blood Pressure

If you do not supply a recent reading, we will not be able to issue a prescription. We now have a blood pressure monitor in the surgery if you don't have access to a machine at home.

Are You A Smoker?: *

If so, would you like help giving up? :

Do you suffer from severe headaches or migraines?: *

Does the migraine affect your vision?: *

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Do you have a history of heart disease or stroke? : *

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

Do you have diabetes?: *

Do you regularly check your breasts?: *

Please ask reception for our information regarding the importance of regular breast self-examination.

Are you experiencing any irregular bleeding?: *

Please book an appointment to see the practice nurse

Have you ever had a Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)?: *

Have any of your parents or siblings had a DVT or PE under the age of 45? : *

Do you have any blood clotting illnesses or abnormalities? : *

Do you have any history of breast cancer or family history of breast cancer under the age of 50? : *

Do you have any history of liver or gallbladder problems? : *

Do you have any history of lupus? : *

Are you due to have any major surgery or have you had any major surgery in the last 3 months? : *

Do you have any problems with your mobility? : *

Do you take any other medications, including over-the-counter medications? : *

Have you used emergency contraception in the last 5 days?: *

Have you had a baby in the last 6 weeks?: *

Do you regularly forget to take a pill?: *

Are you aware how the pill works? : *

Are you aware what to do if you miss a pill?: *

Are you aware that the contraceptive pill may not work if you have diarrhoea or have been vomiting?: *

Are you aware that the contraceptive pill does NOT protect you from sexually transmitted infections, so you will need to use a condom as well?: *

Are you aware that the combined contraceptive pill can increase your risk of stroke, heart attacks and blood clots?: *

Are you aware of other methods of contraception, such as long acting reversible contraception LARCs?: *

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Form: Contraceptive Pill Review

In order to provide another prescription of your contraceptive pill we need to ask you a number of questions.

Please fill out the following information:

Your Recent Blood Pressure

Privacy Consent

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