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.
Please anwser all questions & give as much detail as possible.

Online Contraceptive Pill Check
Name*

Date of Birth*

Phone Number

Will you be 40 years or older within the next 12 months?

What is your current weight? (Kg)

What is your current height ? 

What is your blood pressure?

(Please provide a recent blood pressure reading. This is very important, so please consider purchasing a machine or booking an appointment at the surgery)

Smoking Status: 

If ex-smoker please provide details of how many cigarettes per day and when you stopped smoking.

Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months?*

Deep vein thrombosis (a blood clot in the veins of the leg) 
Pulmonary embolism (a blood clot in the lungs)  
Stroke or cerebro-vascular disease  
Heart disease 
Breast cancer 
None 

Are you currently taking any of the following medications?
Anti-epileptic medication 
Rifampacin -   
St John's Wort -  
None

Do you suffer from Migraines?*

(Aura is a headache associated with weakness or numbness one side of your body or face, difficulty with speech or visual disturbance?

Have you developed any new health conditions or started any new medication in the last 12 months?*
If yes, please give details below.

What is your current method of contraception?*

        

If you are taking the Combined Oral Contraception Pill, how often do you take a break and for how many days?

Have you suffered from of the following in the past 12 months?*
Irregular vaginal bleeding?   
Bleeding after sex?  
Bleeding between periods?   
None

Have you forgotten to take your pill on more than one occasion per month?*
      
If yes please provide details

Do you know what action to take in the event of a missed pill?

Would you like to discuss 'what to do in the event of a missed pill' with you GP or practice nurse?

Would you like to discuss long acting reversible contraception options (coils, implants, injections etc) with you GP or practice nurse?

Is there anything you would like to discuss with one of our Nurses?
We will call you back if requested.

Are you happy with your current method of contraception?*