Annual Contraceptive Pill Review (Pill Check)

Home
My Care
My Appointment
My Record
About Us
Contact

Home
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
Do you have enough of your medication to last the next 4 weeks?*
- Yes
- No
Email
This field is for validation purposes and should be left unchanged.

Policies

Accessibility Statement
Cookies Policy
Feedback & Complaints
Financial Declaration
Medical Disclaimer
Modern Slavery Policy
Non NHS Fees
Statement Of Purpose

Contact Us

01752 346634
@beaconmedgroup
Beacon Medical Group

Careers

Vacancies & Apprenticeships
Placements & Volunteering

Our Practices

Chaddlewood

01752 345317
Glenside

01752 341340
Highlands

01752 897111
Ivybridge

01752 690777
Plympton

01752 346634
Wotter

01752 839312