Contraceptive Pill Review

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

Contraceptive Pill Review

Contraceptive Pill Review

Section

Contraception Pill Review

In KG

Blood Pressure

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Additional Questions

Which pill are you currently taking? *
Are you happy on this pill? *
Smoking Status: *
Do you have any liver/gallbladder problems? *
Do you have a history of severe headaches or migraines? *
Have you ever had a stroke, a blood clot in your lungs or legs, a heart attack or any heart problems? *
Has your mother, father, brother or sister had a blood clot in their lungs or legs under the age of 45 years? *
Has your mother, father, brother or sister had a heart attack or heart problems under the age of 45 years? *
Have you or anyone in your family had breast cancer? *
Do you regularly check your breasts? *
Are you breastfeeding? *
Have you, or any family member, had womb or cervical cancer? *
Are you experiencing any irregular bleeding?
Are you up to date with your smear? *
Are you diabetic? *
Are you epileptic? *
Do you take medication for HIV, TB or Epilepsy or Herbal St John's Wort? *
These can affect some contraceptive efficiency.
Do you have bleeding between your period? *
Do you have have bleeding after sex? *
Have you been given information about long acting reversible contraceptives (Implants, Coils or Injections)? *
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Find out more about the combined pill in theYour Guide to
the Combined Pill leaflet.

Find out more about the progestogen only pill in theYour Guide to the Progestogen Only Pill leaflet.

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