Contraceptive Pill Review

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

Contraceptive Pill Review

Contraceptive Pill Review

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

About You

In Metres

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 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.

Contraception Pill Review

Have you had any problems with your pill? *
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?

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?

Please book an appointment to see the practice nurse

Are you a smoker? *
Would you like help giving up? *
Do you suffer from migraines? *
Have you had any new onset headaches? *
Do you experience visual symptoms or changes in sensation or muscle power on one side of your body? *
Do you know how the pill works? *
Do you know what to do if you miss a pill? *
Please confirm that you are aware of the following: *