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

For women 20 years and older this review will need to be completed once in every 12 months whilst you are taking the Contraceptive Pill.

In order to provide the contraceptive pill safely we need to ask you a number of questions. We would be grateful if you could complete this form when you submit your next repeat prescription request.

If you are having any problems with your medication or would like to consider alternative contraception options, please speak to one of our Practice nurses, who will be able to advise you, or refer you to the Doctor as appropriate.

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please use stone or KG
Please measure your blood pressure using the BP machine at the main surgery waiting room and write your name on the printout.

Contraception Pill Review

Are you a smoker? *
Would you like help giving up smoking? *
Do you regularly check your breasts? *

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

Do you suffer from severe headaches or migraines? *

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

Are you experiencing any irregular bleeding? *

Please book an appointment to see the practice nurse

Do you have any family history of breast cancer under the age of 50? *
Do you suffer from visual symptoms or changes in sensation or muscle power on one side of your body? *
Do you have parents or siblings who have had heart disease or stroke under the age of 45? *
Have you or any family memeber under the age of 45 had a deep vein thrombosis or Pulmonary Embolus (blood clot in the leg or lung)? *
Do you have blood clotting illnesses / abnormalities? *
Do you have Diabetes? *
Are you aware how the pill works? *
Are you aware of what to do if you miss a pill? *
Are you aware that the contraception may not work if you have diarrhoea or vomiting? *
Are you aware that the contraceptive pill does not protect you from Sexually Transmitted Infection (STI) so you will need to use a condom as well to protect yourself? *
Are you aware of the alternatives such as long acting reversible contraception? *

For more information about Long-acting Reversible Contraception (LARC), please visit our Long-acting Reversible Contraception page.

Would you like to book a consultation with a doctor to discuss or arrange fitting a long acting reversible contraception? *

Please remember cervical smear testing. Are you due for your cervical screening test? If you are unsure, please ask at Reception.

  • Every 3 years for women aged 25-50
  • Every 5 years for women aged 50- 65