Contraceptive Pill Review

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

If you have any concerns about your contraception, please make an appointment with a GP or nurse.

Please Note – once you have submitted this information, any reply or acknowledgement from us will be sent to the email address you provide at top of the form. This response may include personal and sensitive information about you. We therefore strongly advise that you provide a personal email address that only you have access to. If you do not wish for us to communicate with you via email, please do not use this form and call us instead.

Contraceptive Pill Review/Pill Repeat Request

If you are human, leave this field blank.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Height:

Weight:

BMI (Body Mass Index)

Smoking Status: *

Smoker (we strongly advise you to stop - if you would like help with this please speak to reception about our in-house clinic)

Never Smoked

Ex-smoker

Blood Pressure (you can use the surgery BP machine to check for free):

How many cigarettes per day do you smoke?

(in numerical digits e.g. '9' not 'nine')

When did you give up smoking?

Do you drink alcohol? *

Yes

No

Number of units per week (one unit = one small glass of wine/half pint of beer)

Contraception Pill Review

Name of your current contraception:

If over 25 have you had a smear test in the last three years? *

Yes

No

Please ask reception about having this done.

Do you have any bleeding between your periods? *

Yes

No

Do you have any bleeding after sex? *

Yes

No

Do you have a history of migraines or severe headaches? *

Yes

No

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? *

Yes

No

Have your mother, father, brother or sister had a had a blood clot in their lungs or legs aged under 60? *

Yes

No

Have your mother, father, brother or sister had a heart attack or any heart problems aged under 60? *

Yes

No

Have you, or anyone in your family, had cancer of the breast? *

Yes

No

Do you self-examine your breasts regularly? *

Yes

No

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

Do you have problems forgetting to take your pill *

Yes

No

We will contact you to discuss

Have you, or any family member, had womb or cervical cancer? *

Yes

No

Have you been given information about long acting reversible contraceptives (Implants, Coils or Injections)? *

Yes

No

If you would like more information please see www.fpa.org.uk or book to discuss these options with our pharmacist or a doctor.

Would you like a sexual health screen? Please see https://www.royalberkshire.nhs.uk/florey-sexualhealth.htm for further details.

I know that missing pills or having severe diarrhoea and vomiting may stop the pill from working effectively and I will need to follow advice in the patient leaflet or contact a doctor for advice

I am requesting this medication for my sole use and not on behalf of another person

I know that if I experience any unexplained pain or swelling in my legs, or unexplained chest pain or shortness of breath, or abnormal vaginal bleeding or migraines to contact my doctor for further advice

*

I confirm that the information provided is accurate to the best of my knowledge