Contraceptive Pill Review

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

Contraceptive Pill Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

About You

eg. 1.75
eg. 60.6

Blood Pressure

Please provide a blood pressure reading if you have access to a machine.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Please use date format: DD/MM/YYYY

Smoking

Smoking status: *

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 have normal periods (menstruation)? i.e. a regular cycle with no excessive or intermenstrual bleeding *
Please describe your cycle:

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

Do you know how to take your medication properly? *
Have you suffered from severe headaches or migraines in the past 3 months?

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

*