Contraceptive Pill Review

Form only to be completed if requested by the practice.

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

In Metres
In KG

Smoking Status

Do you, or have you ever, smoked?
Would you like advice on how to stop smoking?

Blood Pressure

Contraception Pill Review

Do you regularly check your breasts?

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

Do you suffer from severe headaches or migraines?

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

Are you experiencing any irregular bleeding?

Please book an appointment to see the practice nurse

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