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

In CM
In KG

Blood Pressure

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Was this reading done at home or a chemist? *
If you are unable to provide this you can book an appointment with our nurse.

Contraception Pill Review

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

Have you experienced any problems? *
Have you missed any pills? *
Have you had any migraine symptoms? *
Any personal or family history of blood clots? *
Are you a smoker? *
Are your smears up to date? *
*