Contraceptive Pill Review Form PS

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.

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

Yes No

What is your weight approximately? *

What is your height approximately? *

Please provide your latest blood pressure reading below. Please include the date of reading. If you don't have the means to measure your blood pressure at home, please come to the surgery to use our self monitor. No appointment needed

Smoking Status *

Smoker

Ex-Smoker

Non-Smoker

If you are a smoker, Would you like help giving up? ( if yes, please contact our reception on 01798342248)

Yes No

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

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

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

Yes No

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

Yes No

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

Yes No

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

Yes No

Do you need advise about; Protection against sexually transmitted infections, as the contraceptive pill does NOT prevent these so you will need to use a condom as well?

Yes No

To have your annual pill check completed a blood pressure measurement is required. To book your blood pressure appointment with one of our HCA please contact our reception on 01798 342248. If you have a blood pressure monitor at home you can provide this reading instead. Alternatively you can come to the surgery to use the blood pressure self monitor. No appointment needed for this. *

I understand that I will need a blood pressure reading to complete my annual contraceptive pill review

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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