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

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Current Contraception

Are you currently taking a contraceptive pill?
Have you noticed any side effects?
Are you currently taking other medication or have you recently finished a course of any medication?
Do you have any drug allergies?

Health Check

Have you had a blood pressure check in the last 12 months?
Please note – We will be unable to issue the medication without an up to date blood pressure reading. If you do not have access to a blood pressure monitor at home there is one available for use at the surgery.
Have you suffered from high blood pressure, including during a pregnancy?
Do you smoke?
Do you suffer from migraines?
Do you ever get severe headaches at the front/side of your head, with nausea/vomiting, increased sensitivity to light or sound?
Have you ever had a heart attack, stroke or high cholesterol?
Do you have problems with your kidneys or liver? (including hepatitis, tumours)
Do you have any complications from diabetes? (e.g with your eyes, kidneys or sensation in your hands/feet)
Have you ever had any from of cancer? (e.g breast, liver)
Have you or anyone in your family ever had blood clots (e.g. DVT or PE); or have you had major surgery in the last 3 weeks?
Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months?
Do you have any other health problems you thin we should know about? (such as Lupus)

Pregnancy

Are you pregnant or trying to become pregnant?
Have you given birth in the last 3 weeks?
Are you currently breastfeeding?
*
Sending