Contraceptive Pill Review

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

Please fill out all sections of this form, with as much detail as possible to help us process your request as quickly as possible. If there are no concerns from the clinician, your prescription will available for you to collect from your nominated pharmacy up to 5 working days from submission of this form.

Contraceptive Pill Review

Contraceptive Pill Review

If you are human, leave this field blank.

Section

Contraception Pill Review

What is the name of the contraceptive pill you are requesting? *

If you are unsure and you want the same one as last time, simply write 'same'.

Have you started taking any new regular medications, either prescribed or over the counter, since we last prescribed the pill for you? *

Yes

No

Please give further details: *

Have you been diagnosed with any new medical conditions since we last prescribed the pill for you? *

Yes

No

Please give further details: *

Do you suffer from severe headaches or migraines? *

Yes - But the Doctor is unaware

Yes - But the Doctor is aware

No

Please give some details about your headaches or migraines. For example, how often do they occur? What do they feel like when you get them? Do you get any other symptoms either before or during the headaches, for example vomiting, visual disturbances, numbness or pins and needles? *

Have you yourself ever had a blood clot in the leg (DVT - deep vein thrombosis) or a blood clot in the lung (PE - pulmonary embolism)? *

Yes

No

Have any of your family members ever had a blood clot in the leg (DVT - deep vein thrombosis) or a blood clot in the lung (PE - pulmonary embolism)? *

Yes

No

Please indicate their relation to you and the approximate age it occurred: *

Have you ever been diagnosed with breast cancer? *

Yes

No

Have any of your family members ever been diagnosed with breast cancer? *

Yes

No

Please indicate their relation to you and the approximate age of diagnosis: *

What is your smoking status? *

Smoker

Ex smoker

Never smoked

How many cigarettes do you smoke per day? *

Are you up to date with your cervical screening (smear test)? *

Yes

No

To safely prescribe the contraceptive it is important we have a record of a recent blood pressure reading from you. Please provide a recent reading in the box below, if you are unable to check your blood pressure yourself you will need to get this done either at a local chemist or by booking an appointment at the practice.

Blood pressure reading: *

Systolic "Higher" / Diastolic "Lower"

Please enter your height in centimetres: *

Please enter your weight in kilograms: *

Are you having any problems with your current pill that you would like to discuss with us? *

Yes

No

Please give further details: *

If there are no concerns from the clinician, your prescription will available for you to collect from your nominated pharmacy up to 5 working days from submission of this form.

*

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