Contraceptive Pill Review

Section

Have you received a letter advising you to complete this review?

Yes

No

Please specify requester and date of letter:

Please use date format DD/MM/YYYY.

Contraception Pill Review

Height *

In Metres

Weight *

In KG

Do you regularly check your breasts?

Yes

No

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

Do you suffer from severe headaches or migraines?

Yes - But the Doctor is unaware

Yes - But the Doctor is aware

No

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?

Yes

No

Please book an appointment to see the practice nurse

Do you currently smoke?

Yes

No

Do currently smoke section

How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking?

Yes

No

Do not currently smoke section

Have you smoked in the past?

Yes

No

How many cigarettes did you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Have there been any changes in your family history since your last prescription (e.g. blood clots or breast diagnosis in close blood relatives)?

Please provide any concerns you have:

*

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

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