Contraceptive Pill Review

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

Contraceptive pills may cause serious complications in a few people.

These questions help us to identify those who may be at risk of complications therefore, it is essential for your own safety that you answer all of the questions accurately. It is your responsibility to ensure that the answers you give are honest and accurate.

In order to complete this questionnaire, you will require a blood pressure reading obtained within the last month. A blood pressure machine is available for you to use in the waiting room.


Contraceptive Pill Review

Contraceptive Pill Review

Provided the answers you give indicate that there are no concerns with continuing your current pill your prescription will be reauthorised for 12 months and sent to your nominated pharmacy.

If your answers suggest that you may be better suited to an alternative form of contraception you will receive a text message advising you to make an appointment with our Woman's Health Advisor.

About You

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

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?
Have you had an episode whereby your migraine has been accompanied by any of the following?

- visual problems - such as seeing flashing lights, zig-zag patterns or blind spots
- numbness or a tingling sensation like pins and needles
- feeling dizzy
- difficulty speaking
- loss of consciousness

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

Do you have a history of cancer?
Do you have any first degree relatives (mother, father or siblings) who have had breast cancer, a stroke of a blood clot?
Are you a current smoker?
If you are an ex-smoker, have you stopped within the last 12 months?
Are you currently pregnant or breastfeeding?
Are you experiencing any irregular bleeding?

Please book an appointment to see the practice nurse