Contraceptive Pill Review

If you have been advised by the surgery to submit a contraceptive pill review please use this form.

Contraceptive Pill Review

Contraceptive Pill Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Contraception Pill Review

Do you need a repeat of your current contraception?

Please check your blood pressure:

/
Smoking status:
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY
Do you have any irregular bleeding? This includes bleeding or spotting in between your periods or after sexual intercourse
Do you have a history of abnormal smear tests?
Do you perform regular breast examinations on yourself?
For more information please see this leaflet about being breast aware.
Do you currently have or have you ever previously suffered from diabetes, DVT (blood clots), breast cancer, cardiovascular disease, liver disease or migraines?
Does anyone in your family have a history of cardiovascular disease, stroke or breast cancer?
*
Sending