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

Have you ever used this contraceptive? *
What is your main reason for using this contraceptive? *
Are you taking this contraceptive now? *
How long have you been taking this contraceptive? *
Did you miss any pills in the last two months? *
Do you experience any side effects from this contraceptive? *
Has any doctor, nurse or other healthcare provider told you in the past you should not use an oral contraceptive? *

Healthcare

When did you last have your cervical smear? *
Cervical Screening is offered free of charge to most women from the age of 25. It is done to pick up changes in a woman's cervix that may in time progress to cancer. It has been shown to be effective in reducing cancer rates. We encourage you to follow the advice that women have regular smear tests.
Please confirm if you understand this: *
Do you experience any abnormal or undiagnosed vaginal bleeding (that is bleeding other than your period, such as bleeding in between periods or bleeding after sex)? *
Do you regularly check your breasts for signs of changes? *

Pregnancy

Are you sure you are not currently pregnant? *
Have you ever been pregnant? *

About You

Do you smoke? *
Have you ever had cancer? *
Have you ever had a stroke, a blood clot in your legs or lungs, a heart attack or heart problem? *
Have you ever been diagnosed with diabetes or abnormal blood sugar levels? *
Do you have high cholesterol? *
Have you ever been diagnosed with a liver condition? *
Have you ever suffered from migraines or severe headaches? *
Are you due to have any major surgery or have you had a major surgery in the past three months? *
Do you have any problems with mobility? *
Other than those already mentioned, do you have any other significant medical conditions, illnesses or past surgical procedures of concern? *

Family History

Has anyone in your family ever had a blood clot in the legs or lung? *
Has anyone in your family ever had a heart attack or stroke? *
Has anyone in your family had cancer of the breast womb or ovary? *

Your Height and Weight

Metres / cm
KG

Your Blood Pressure

What is your blood pressure? *
Do you have a history of high blood pressure or are you on any treatment for high blood pressure? *

Declaration

*
*

Next Steps

A member of our administration team will now look into your request for the contraceptive pill, if issued this will be sent directly to your nominated pharmacy.

You may be asked to attend the surgery for blood pressure monitoring.

Finally we ask that you confirm the following:

*