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

About You

Are you able to provide your height? *

Please book a Patient Pod appointment by contacting the practice so that we can capture this information.

In Metres
Are you able to provide your weight? *

Please book a Patient Pod appointment by contacting the practice so that we can capture this information.

In KG
Are you able to provide a blood pressure reading? *

Please book a Patient Pod appointment by contacting the practice so that we can capture this information.

Blood Pressure

Please use date format: DD/MM/YYYY

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Smoking

Smoking status: *
Would you like help to give up smoking?

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? *

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

*