Contraceptive Pill Review

If you have been advised by the surgery to submit a contraceptive pill review please fill-in this form and then use the automated machine at the surgery for BP/weight.

Contraceptive Pill Review

Contraceptive Pill Review

You must be between the ages of 18-50 with a BMI below 30 to use this form - If not please book an appointment with reception.

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
please give in cm
please give in kg
Smoking Status
If you smoke, we strongly advise that you stop. If you would like help with this, please complete our self-referral smoking cessation form.
Do you drink alcohol?
(1 unit = small glass of wine or half pint beer)

Contraceptive Pill Review

Do you have bleeding between your periods?
Do you have bleeding after sex?
If over 25, have you had a smear test in the last 3 years? If not please book in at reception to have this done.
Do you have a history of migraines or severe headaches?
Do you have problems with forgetting to take your pills?
Have you ever had a stroke, a blood clot in your legs or your lungs, a heart attack or any heart problems?
Have your mother, father, brother or sister had a blood clot in their legs or lungs aged under 60 years?
Has your mother, father, brother or sister has a heart attack or stroke ages under 60 years?
Has anyone in your family had cancer of the breast?
Do you take medication for epilepsy?
Have you been given information about long acting reversible contraceptives (implants, coils, injections)

Please book an appointment with a Nurse/Doctor.

If you would like more information, please see www.fpa.org.uk or book to discuss these options with a family planning nurses/doctor.

Would you like a sexual health screen? Please see Royal Berkshire Sexual Health for further details.

Informed Consent:

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