Contraceptive Pill Review

Please complete the following questions to allow your health care professional to assess your current contraception.

This questionnaire is for a routine review of your use of contraception. If you are experiencing any of the following, please ring your GP immediately:

  • A bad headache, or migraines.
  • Painful swelling of your leg.
  • Weakness or numbness of an arm or leg.
  • Sudden problems with your speech or sight.
  • Difficulty breathing.
  • Coughing up blood.
  • Pains in your chest, especially if it hurts to breathe in.
  • A bad pain in your tummy (abdomen).
  • A faint or collapse.
Contraceptive Pill Review

About You

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

Your Current Health Details

In KG
In M
in mmHg
in mmHg
in BPM

Your Medical History

(e.g. Deep Vein Thrombosis or Pulmonary Embolism)
Please select all that apply

Alternative Contraception

(e.g. contraceptive implant or coil)

Alcohol and Smoking Questions

For further information, please see www.nhs.uk/smokefree

Further Information

After completing all of the above questionnaire, please click submit below. Your GP practice will then inform you if your oral contraception repeat prescription is ready for collection or if a further assessment is required.