Contraceptive Pill Check Form - Colton Mill Medical Centre

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

Smoking status *

If you are a smoker, how many do you smoke a day?

If you are a smoker, would you like help to stop smoking?

Yes No

What is the current pill that you are taking?

If you have checked your blood pressure, please tell us the reading and the date this was taken (if you have not had your blood pressure checked within the last 12 months, please arrange for this to be checked before your next prescription is due)

How many units of alcohol do you normally drink each week on average? *

If you drink more than 14 units per week, would you like to discuss your drinking habits further and seek advice and support?

What is your current weight? *

Would you like support and advice about weight management? *

Yes No

How much exercise do you normally do on average each week? (Please state the type of exercise) *

Do you want to discuss changing your contraception (e.g. to coil, implant, injection, a different type of pill)? *

Yes No

Have you previously discussed alternative choices of contraception and the possible risks with a health professional? *

Yes No

Do you know what to do if you miss a pill? *

Yes No

Do you ever suffer with migraines? *

Yes No

Do you ever suffer from headaches? *

Yes No

If yes, are they are accompanied by visual disturbances or aura? *

Yes No

Have you ever been advised that you have had a blood clot such as Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)?

Do you have a 7-day break on your current pill regime? *

Yes No

Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? *

Yes No

Have you noticed any new and unusual vaginal discharge? *

Yes No

Do you feel you need any sexual health screening such as, chlamydia screening? *

Yes No

Do you examine your breasts regularly to detect for any lumps? *

Yes No

Do you have any family history of breast cancer, heart disease or strokes? (Please state who and what ages they were if known) *

Please confirm that the information provided has been provided by the patient named on the form? *

Yes No

Contraceptive Pill Review Form

Further Information