Annual Contraceptive Pill Review Annual Contraceptive Pill Review Name First Last Contact NumberEmail Enter Email Confirm Email Date of Birth Day Month Year Type of Combined Hormonal Contraception Pill Ring Patch How do you take the contraceptive pill? Traditional Method (Once daily for 3 weeks, followed by a one week break) Optional Tailored Method (As set out by Clinician) Optional Name of current contraceptionAre you satisfied with your current method of contraception? Yes No Are you looking at stopping or changing your contraceptive method in the next 12 months? Yes No Are you aware of the alternatives such as long acting reversible contraceptive? Yes No Are you a smoker? Yes No Are you a smoker over the age of 35? Yes Optional No Optional Is your BMI >35?Please calculate using current weight and height https://www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx# Yes No HeightWeightBMIPlease state Blood PressureDo you knowingly have a q-risk >10 or a past history of heart disease, stroke, TIA or arterial disease? Yes No Have you or any family member, had a deep vein thrombosis or pulmonary embolus (blood clot in the leg or lung), under the age of 45?* Yes No Are you currently immobile? Yes No Do you suffer from migraines? Yes No Do you suffer from visual symptoms prior to the migraine headache? Yes No Do you have a current history or past history of breast cancer? Yes No Have you got a private prescription for the weight loss injection Ozempic or Mounjaro? Yes No Do you have uncontrolled diabetes? Yes No Have you developed any new symptoms or bleeding patterns since your last review? Yes No Have you had any changes to your medical / family / drug history since your last review? Yes No Are you aware how the pill works? Further information on the FPA or BMG websites. Yes No Are you aware what to do if you miss a pill? Yes No Are you aware that the contraceptive pill does NOT protect you from Sexually Transmitted Infection (STI), so you will need to use a condom as well to protect yourself? Yes No Would you like to book a consultation with a health care professional to discuss or arrange fitting a long acting reversible contraceptive? Yes No Do you have enough of your medication to last the next 4 weeks? Yes No
