Contraceptive Pill Review Form

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

Last Updated: 29/11/2019

YOUR DETAILS

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Date of Birth Required
Required
Required

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CONTRACEPTIVE PILL REVIEW

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Consent Required
Will you be 35 years or older within the next 12 months? Required
Smoking Status Required
Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months?
Have you been diagnosed with or experienced any of the following conditions in the past 12 months?
Are you currently taking any of the following medications?
Do you suffer from migraines with aura, or a headache associated with weakness or numbness on one side of your face or body, or difficulty with speech? Required
Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? Required
Have you forgotten to take your pill on more than one occasion per month?
Would you like to discuss 'what to do in the event of a missed pill' with you GP or practice nurse? Required
Would you like to discuss long acting reversible contraception options with you GP or practice nurse? Required

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. 

Consent Required
Required