Contraceptive Review

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

Contraceptive Review

Contraceptive Review

About You

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

Contraception Review

In Metres
In KG
Type of hormonal contraception: *
Have you had a baby in the past 6 weeks? *
Are you currently breastfeeding? *
Have you missed any pills in the last 4 weeks? (other than normal pill-free periods) *
Have you had any new abnormal/unexpected bleeding since your last review? *
Have you had a recent blood pressure check? *

Please state your most recent blood pressure reading:

Are you a smoker? *
Have you been diagnosed with any new health conditions over the past year? *
Do you have any history of heart disease, stroke, TIA or arterial disease? *
Do you suffer from headaches or migraines? *
Do you suffer from visual symptoms prior to the migraine or headache? *
Have you or any family member, had a deep vein thrombosis or pulmonary embolus (blood clot in the leg or lung), under the age of 45? *
Do you have a current history or past history of breast cancer? *
Do you have uncontrolled diabetes? *
Have you had any changes to your medical/family/drug history since your last review? *
Are you aware of how the pill works? *
Would you like more information about 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? *
Do you regularly check your breasts? *
*