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Home > Reception: Contraception Options

Reception: Contraception Options

There are lots of different methods of contraception available and different types will suit different people.

Methods can be hormonal or non hormonal.

Non hormonal methods include the copper coil and barrier methods, such as condoms or the female diaphragm or condom.

Hormonal methods include pills, a patch, vaginal ring or contraceptive injection. Or there are longer acting methods such as hormonal coils and the implant.

The NHS website below contains lots of useful information about these different methods.

www.nhs.uk/contraception/

Please look through this website and then fill in as much information as possible.

Some of this information will already be included in your medical notes but this is a good opportunity to update any changes.

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 316711. We will start to process your form by the next working day but it will take up to 1 working day to complete. Please DO NOT call before 1 working day as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Personal details

Full name

Date of Birth (DD/MM/YYYY):

Contact number (preferably mobile if possible)

Current contraception

Please tell us a bit about what method of contraception you are currently using:

Do you know what method of contraception you would like to use or change to?

Have you tried different methods of contraception in the past?If yes, what have you used and did it suit you? If it did not suit you please explain why not or what you didn't like.

Health information

Sometimes other health problems or medication can affect the types of contraception that are safe to use. Answering these questions will help us work out which options are best for you.

Do you know your blood pressure?

What is your height?

What is your weight?

What is your smoking status?

How many units of alcohol do you consume a week?

Have you given birth within the last 12 weeks?If yes please let us know if you are breastfeeding

Please tick the box against any conditions you have been diagnosed with:

None

Heart disease, high blood pressure or stroke

Blood clots

Breast cancer

Carrier of gene mutation associated with breast cancer e.g. BRCA1 or 2

Migraine

Liver Problems

Diabetes

Pregnancy complications (e.g. high blood pressure or cholestasis)

Current unexplained vaginal bleeding or bleeding after sex

High cholesterol

Previous abnormal cervical smear

HIV/AIDS

Gallbladder disease

Thrombophlebitis (inflammation of varicose veins)

Inflammatory bowel disease

Sickle cell disease

Raynaud’s disease

Rheumatoid arthritis/lupus

Atrial fibrillation

Immobility

Please tick the box next to any conditions that are present in your family:

None

Heart disease, high blood pressure or stroke

Blood clots

Breast cancer

Carrier of gene mutation associated with breast cancer e.g. BRCA1 or 2

If you have ticked against a condition above, please provide details of age at time of diagnosis and relationship to you

Please list any current medications including over the counter medications (If you do not take any other medications please write NIL):

Do you have any allergies? (If no write nil, if yes please give details)

And some final details

How would you like us to respond?

Please tick to confirm that you have read through the link above which relates to contraceptive options

Please tick to confirm that you are aware that condoms are the only method of contraception which protect against Sexually Transmitted Infections

Please tick to confirm that the information provided is accurate to the best of your knowledge

Thank you for completing this form

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