Contraceptive Pill Annual Review

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

What is the name of your contraceptive pill? *

Height *

Weight *

Smoking Status *

Smoker

Ex-Smoker

Non-Smoker

Please provide a recent blood pressure reading. If you are unable to check your BP at home, please make an appointment with our health care support worker. *

Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months?

Deep vein thrombosis (a blood clot in the veins of the leg)

Pulmonary embolism (a blood clot in the lungs)

Stroke or cerebro-vascular disease

Heart disease

Have you been diagnosed with or experienced any of the following conditions in the past 12 months?

Are you currently taking any of the following medications?

Anti-epileptic medication

Rifampacin

St Johns Wort

Do you suffer from migraines with aura, or a headache associated with weakness or numbness on one side of your face or body, or difficulty with speech? * *

Yes No

Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? * *

Yes No

Have you forgotten to take your pill on more than one occasion per month? *

Yes No

Please confirm that you have read, 'what to do in the event of a missed pill' on the patient information leaflet in your pill pack: *

I confirm that I have read "what to do in the event of a missed pill" on the patient information leaflet in my pill pack

The contraceptive pill does not protect you against sexually transmitted infections. Please confirm that you have read the information on STIs from the Family Planning Association in the link below: *

I confirm that I have read and understood the information on STIs on the Family Planning Association website

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Contraceptive Pill Annual Review

Further Information