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Home > Reception: Contraceptive Review "Pill Check" & Medication Review

Reception: Contraceptive Review "Pill Check" & Medication Review

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

You will need an up to date weight and blood pressure.

Information on various contraceptive can be found below:

Combined pill

Progesterone only pill

Contraceptive patch

Vaginal ring

It is advised where possible to consider long acting contraceptive options like the implant or coil. To find out more information or book your appointment for long acting contraception please click the link below:

Coil & Implant

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 3 working days to complete. Please DO not call before 3 working days 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.

Reception: Contraceptive Review "Pill Check" & Medication Review

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

Do you suffer from migraine headaches?

What form of contraception are you currently using?

Would you like to continue with your current method?

If no, why not? And which alternative would you like to use?

Medical history

Some medical conditions can mean hormonal contraception is not a safe option. Please answer the following questions below about your own health and family history.

Are you experiencing any irregular or unusual bleeding?This could be inbetween your periods if you have a regular cycle, or after sex

Have you experienced any new medical problems since your last contraceptive review?If you select yes please make a telephone appointment to discuss this with one of our clinical team.

Have you noticed any new headaches since starting your current method of contraception?

What is your current blood pressure?e.g. 120/80 (Upper valve/Lower value). If you do not know your blood pressure then you will need to have your blood pressure checked by using a home BP monitor, attending a chemist or booking an appointment at the surgery before your prescription can be issued.

What is your current height? (include units e.g. metres or feet)

What is your current weight?In Kg or Stones & lbs

Smoking History

Have you given birth within the last 6 weeks

Are you currently 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. BRCA 1 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. BRCA 1 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 NO, if yes please give details)

Prescription details

If approved which pharmacy would you like us to send your prescription too?

If other please state pharmacy name & postcode

I confirm I have read through the links above which relate to my contraception option and understand what to do if I miss a dose or experience diarrhoea/vomiting

I understand that condoms are the only method of contraception that protects against Sexually Transmitted Infection; And that whilst it may not suit me at the moment I have considered a longer acting method of contraception (e.g. implant or coil)

Do you have any concerns or side effects from your medication?This relates to all your medications if you are on more then just the oral contraceptive. Please state the medication and the side effect. E.g. Paracetamol: Constipation

Do you know when and how to take your medication?

Are you on any antidepressant medication?If you are struggling with your mental health please contact the practice or if out of hours or in an emergency call the CRISIS team: 0300 200 0011 and select option 1.

If you are on antidepressants, can you please select the option which best applies to you?

I confirm that the information provided is accurate to the best of my knowledge

It is important that you complete a cervical smear regularly.

under 25 up to 6 months before you turn 25

25 to 49 every 3 years

50 to 64 every 5 years

65 or older only if 1 of your last 3 tests was abnormal

Do you take an over the counter, herbal remedies or specialist medication? If no write: NO. If yes, please state the name and dose of these medications.

Thank you for completing this form

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This information is retained for up to 28 days.

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