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.

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.

In Metres

Blood Pressure

Contraception Pill Review

Do you think your pill is causing you side effects? *
Have you suffered from severe headaches or migraines since your last review? *
Have you or a close family member had a blood clot since your last review? *
Have you seen another doctor outside of this practice since your last review? *
Have you had any bleeding/spotting in between periods since your last review? *
Have you had any bleeding after sex since your last review? *
Are you aware of what to do if you miss a pill or have diarrhoea or vomiting? *
Have you had any abnormal discharge since your last review? *
Do you regularly check your breasts? *
Do you smoke? *