Contraceptive Pill Review

Can we contact (call or text) you on this number? *

Yes

No

Date:

About You

Height *

In Metres

Weight *

In KG

Blood Pressure Reading

If you don’t have a machine or don’t have access to a machine, we’d recommend you buy one.

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

Alternatively, you will need to book an appointment with our nursing team to get it checked, especially if you are on a combined pill, as the Faculty of Family Planning recommends that you have an annual BP check.

Systolic 'Higher':

Diastolic 'Lower':

Heart Rate:

Contraception Pill Review

What is the name of the pill that you are currently on? *

Have you had any problems with your pill? *

Yes

No

Please detail any issues: *

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

Are you a smoker? *

Yes

No

Would you like help giving up? *

Yes

No

Do you suffer from migraines? *

Yes

No

Have you had any new onset headaches? *

Yes

No

Do you experience visual symptoms or changes in sensation or muscle power on one side of your body? *

Yes

No

Do you know how the pill works? *

Yes

No

Do you know what to do if you miss a pill? *

Yes

No

Please confirm that you are aware of the following: *

That the combined contraceptive pill may increase your chance of DVT/ clots in legs.

That the contraceptive pill does not protect you from sexually transmitted infections, so you will need to use a condom as well to protect yourself.

That the pill absorption may be affected if you have long-term diarrhoea and vomiting.

*

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

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