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
Have you been experiencing side effects since you started taking the pill? *

Your Medical History

Do you currently experience, or have a history of Migraines?
Have you ever had any blood clots?
(e.g. Deep Vein Thrombosis or Pulmonary Embolism)
Have you ever had a heart attack or stroke?
Have you ever had breast or cervical cancer?
Do you have a family history of any of the following?
Please select all that apply

Alternative Contraception

Would you like any further information about Long Acting Reversible Contraception? *
(e.g. contraceptive implant or coil)
If you would like to receive further information about alternative contraception, please select the options you are interested in:

Alcohol and Smoking Questions

How many units of alcohol do you drink on a typical day drinking?
How often have you had 6 or more units on a single occasion in the last year?
Do you smoke?
Do you use an e-cigarette (vape)?
If you smoke, would you like help to quit smoking?
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.