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Staunton & Corse Surgery NHS GP Surgery in Gloucestershire

Contraceptive pill review

Contraceptive Pill Review

Required fields are labelled

Who are you completing this form for? Required

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name? Required

First name

Last name

What is your date of birth? Required

For example, 31 3 1980

Day

Month

Year

What is your sex? Required

As recorded on your medical record

Male

Female

Other

What is your postcode? Required

The one used to register with your GP

What is your phone number? Required

What is your email address? Required

Anyone else with access to your email account may see responses sent to you

Home Address (including postcode): Required

It is important we have up to date measurements of your weight, height and blood pressure. Please supply us with measurements done within the last 2 weeks.

If you are a member of a gym or have your own equipment to use that is fine. Blood pressure monitors are available to purchase at pharmacies or online.

Height Required

In Metres

Weight Required

In KG

Blood Pressure

Systolic “Higher” Required

Diastolic “Lower” Required

Heart Rate

Contraception Pill Review

What contraceptive pill are you currently taking?

How often do you forget to take a pill? Required

Do you think your pill is causing you side effects? Required

Yes

No

Have you suffered from severe headaches or migraines since your last review? Required

Yes

No

Have you or a close family member had a blood clot since your last review? Required

Yes

No

Have you seen another doctor outside of this practice since your last review? Required

Yes

No

Have you had any bleeding/spotting in between periods since your last review? Required

Yes

No

Have you had any bleeding after sex since your last review? Required

Yes

No

Are you aware of what to do if you miss a pill or have diarrhoea or vomiting? Required

Yes

No

Have you had any abnormal discharge since your last review? Required

Yes

No

Do you regularly check your breasts? Required

Yes

No

Do you smoke? Required

Yes

No

How many do you smoke per day? Required

Confirmation Required

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

Confirmation Required

I understand it may take a week for the pill review to be completed and that I will be contacted if further information is required

If you are human, leave this field blank.

Gloucester Road
Corse
Gloucester
Gloucestershire
GL19 3RB

Get directions

01452 840228

About the surgery

Register with the surgery

Sick (fit) notes

Feedback and complaints

Staunton and Corse Surgery

CQC overall rating

Good

1 June 2016

See the report

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