Contraceptive Pill Review

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

Please ensure that you answer the questions accurately. We use the information provided to offer the most suitable treatment for you and to assess whether it is safe for you to continue using your current contraceptive medication.

Contraceptive Pill Review

Contraceptive Pill Review

About You

In Metres
Do you currently smoke?
How many cigarettes do you smoke in a day?
Have you smoked in the past?
How many cigarettes did you smoke in a day?
Any family history of breast cancer?
Any personal or family history of blood clots or strokes?
Any history of liver disease?

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