Contraceptive Pill Review/Pill Repeat Request Form

If you have been advised by the surgery to submit a contraceptive pill review please use this form. It is intended for patients who have had the pill continuously for the last six months or longer and are aged 18 to 55.

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Contraceptive Pill Review/Pill Repeat Request

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Smoking Status: *
(in numerical digits e.g. '9' not 'nine')
Do you drink alcohol? *

Contraception Pill Review

If over 25 have you had a smear test in the last three years? *

Please ask reception about having this done.

Do you have any bleeding between your periods? *
Do you have any bleeding after sex? *
Do you have a history of migraines or severe headaches? *

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Have you ever had a stroke, a blood clot in your lungs or legs, a heart attack or any heart problems? *
Have your mother, father, brother or sister had a had a blood clot in their lungs or legs aged under 60? *
Have your mother, father, brother or sister had a heart attack or any heart problems aged under 60? *
Have you, or anyone in your family, had cancer of the breast? *
Do you self-examine your breasts regularly? *

Please ask reception for our information regarding the importance of regular breast self-examination.

Do you have problems forgetting to take your pill *

We will contact you to discuss

Have you, or any family member, had womb or cervical cancer? *
Have you been given information about long acting reversible contraceptives (Implants, Coils or Injections)? *

If you would like more information please see www.fpa.org.uk or book to discuss these options with our pharmacist or a doctor.

Would you like a sexual health screen? Please see www.royalberkshire.nhs.uk/florey-sexualhealth for further details.

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Sending