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

Are you happy with the contraceptive pill? *
Please book a telephone appointment to discuss this with the doctor. Your pill prescription cannot be issued until this appointment has taken place.

Do you have issues taking the pill regularly and on time? *
Are you taking the: *
Do you regularly check your breasts?
Do you suffer from severe headaches or migraines?

Combined Pill

Unit of measurement: *
Unit of measurement: *
Any new medical diagnosis since the last pill review? *
Please see NHS: Combined Pill for relevant conditions.

Current Blood Pressure

Your pill prescription cannot be issued without an up to date blood pressure reading.

If you need to use our blood pressure machine, please visit the surgery reception.

Smoking

Smoking status: *
Please select all that apply:

Progesterone Only Pill

Have you had any change in bleeding pattern since the last review? *
Please book a telephone appointment to discuss this with the doctor. Your pill prescription cannot be issued until this appointment has taken place.
Any new medical diagnosis since the last pill review? *
Please see NHS: Progesterone Only Pill for relevant conditions.
*