Annual Contraceptive Pill Review (Pill Check)

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My Care
My Appointment

My Record
About Us
Contact

Annual Contraceptive Pill Review

Name Of Patient*
Contact Email Address*
Contact Phone Number*
Patient Date Of Birth*
Type of Combined Hormonal Contraception*
- Pill
- Ring
- Patch
Name of current contraception*
Are you satisfied with your current method of contraception?*
- 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 years?
- Yes
- No
Is your BMI > 35?*
- Yes
- No
Please calculate using current weight and height https://www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx#
Height*
Weight*
BMI*
If your BP greater than 140/90mmHg?*
- Yes
- No
Please State BP*
Do 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
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 contraception may not work if you have diarrhoea or vomiting?*
- 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
Name
This field is for validation purposes and should be left unchanged.

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