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

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Unit *
Unit *
Systolic "Higher" / Diastolic "Lower" / Heart Rate

Contraception Pill Review

Which pill are you currently taking? *
What regime are you taking? *
Are you fully understanding of the regime you use and are compliant? *
Do you understand what to do in the event of missing pills? *
Are you happy on this pill? *
Smoking Status: *

We advise all smokers that they should stop smoking. Smoking does increase the risk of circulatory problems, particularly women on the pill. If you would like help to stop, please visit the onecare website.

Do you have any liver/gallbladder problems? *
Do you have a history of severe headaches or migraines? *
Do you suffer from:

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

Have you ever had a stroke, a blood clot in your lungs or legs, a heart attack or any heart problems? *
Has your mother, father, brother or sister had a blood clot in their lungs or legs under the age of 45 years? *
Has your mother, father, brother or sister had a heart attack or heart problems under the age of 45 years? *
Have you or anyone in your family had breast cancer? *
Do you regularly self examine your breasts? *
Are you breastfeeding? *
Have you, or any family member, had womb or cervical cancer? *
Are you up to date with your smear? *
Are you diabetic? *
Are you epileptic? *
Do you take medication for HIV, TB or Epilepsy or Herbal St John's Wort? (these can affectsome contraceptive efficacy) *
Do you have bleeding between your period? *
Do you have have bleeding after sex? *
Have you been given information about long acting reversible contraceptives (Implants, Coils or Injections)? *


Find out more about the combined pill in the Your Guide to
the Combined Pill leaflet

Find out more about the progestogen only pill in the Your Guide to the Progestogen Only Pill leaflet.

I give my consent for SMS text messaging: *

If you are under the age of 24 years it is advisable to perform annual Chlamydia tests, or with every change of sexual partner. Chlamydia can often be present without symptoms but can cause complications to fertility.

If this is applicable to you, please collect a Chlamydia testing kit from reception, complete the test, peel off one of the stickers on the form and apply to the tube and return the kit back to surgery.

You will then be notified of the result by the Chlamydia Screening Team and treated by them if required. The result will not be shared with the surgery.