Contraceptive Pill Review

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

If you are a student at University of Surrey, please contact reception to book a self-check blood pressure and weight slot at the Uni health centre, then add the readings to the section below.

Contraceptive Pill Review

Contraceptive Pill Review

Your Pill

How long have you been taking this pill?
Are you happy to use the Electronic Prescription Service (EPS)?
Do you give permission to text to confirm your prescription has been sent to the pharmacy?

Your Medical History

Please select all that apply to you.
Have you had any problems with your current pill or are you unhappy with it?
Have you ever had any kind of migraine? (i.e. a severe headache with a dislike of noise or light, visual disturbances or sickness)
Have you experienced any unexpected or unusual bleeding?
Have you had any episodes of DVT (deep vein thrombosis) or blood clot in your leg or lung? (i.e. a clot requiring blood thinning medication such as warfarin or rivaroxaban)
Has any of your immediate family had a DVT/blood clot to legs or lungs?
Has any of your immediate family had a heart attack or stroke at age 45 years or under?
Do you have a family history of breast cancer?
Have you ever had problems with your liver?
Have there been any changes to your health since you were last seen?
Are you taking St John’s Wart (an herbal anti-depressant) or any other medication we are not aware of?

About You

Smoking status:
Would you like smoking cessation advice?
In CM
In KG
In mmHg

If your readings are either above 140 systolic (top number) or above 90 diastolic (bottom number), please repeat two more times.

In mmHg
In mmHg

Declaration

I hereby declare that the information I have supplied on this form is true and correct to the best of my knowledge.