Contraceptive Pill Review

About You

In Metres
In KG

Blood Pressure

If you are unable to provide a blood pressure reading, you can book an appointment with our health care assistant or we will contact you when we review your form.

Was this reading done at home or chemist?

Contraception Pill Review

Do you regularly check your breasts?

Please ask reception for our information regarding the importance of regular breast self-examination.

Do you suffer from severe headaches or migraines?

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Are you experiencing any irregular bleeding, for example after intercourse or between periods?

Please book an appointment to see the practice nurse

Have you experienced any problems with taking your pill since your last review?
Have you missed any pills?
Do you know what to do if you miss a pill or you have vomiting or diarrhoea?

More information can be found by visiting: What if I’m on the pill and I’m sick or have diarrhoea? – NHS (www.nhs.uk)

Do you have any personal or family history of blood clots?
Are you a smoker?
Are your smears up to date?
Do you have any family history of breast cancer in your immediate family (parents/siblings)?
Long Acting Reversible methods of contraception, such as the Mirena and implant, are better at preventing pregnancy. You can find more information by visiting www.patient.info/long-acting-reversible-contraceptives-larc. Would you be interested in these methods?
Please confirm that you have no new concerns about this pill: *