Contraceptive Pill Review / Request

Section

About You

Allergies:

Preferred pharmacy to collect your prescription: *

Please include pharmacy name, address and postcode

Current medications and contraception (if applicable):

Blood Pressure Reading

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors.

If you are unable to provide a reading, please contact the surgery to discuss your options as failure to provide a blood pressure reading will mean we are unable to complete your prescription request.

Date of reading: *

Please use date format: DD/MM/YYYY

Systolic "Higher" *

Diastolic "Lower" *

Heart Rate *

Height *

In Metres

Weight *

In KG

Have you had any changes to your health since the last pill check? *

Yes

No

Please specify: *

The progesterone only pill (POP) and Combined Oral Contraceptive (COCP) are taken daily and with typical use they are 91% effective preventing a pregnancy. Long acting contraception such as IUD(coil), implant and injections are better at preventing a pregnancy. None of these methods protect you against sexually transmitted infections such as herpes, chlamydia, HIV. If you are worried about STIs, for more info visit www.essexsexualhealthservice.org.uk or speak to your GP.

To read more about how the oral contraception works, their benefits, side effects and risks as well as alternative contraception options such as long acting contraception visit www.patient.info/health/contraception-methods

If you are having issues with your current contraception, please book an appointment with your GP to discuss your options further.

Before prescribing you oral contraception, we will ask you some questions about your health - a GP will review your answers to ensure we prescribe safely. Once you are prescribed the pill, it will be added to your repeat list for a total of 12 months which you can request online or via repeat prescription service in the surgery manually. After a year you will need to come back or fill a new form for a review unless there is any change earlier in your circumstances or you have any concerns.

Have you had a 'normal' period in the last 4-5 weeks? *

Yes

No

First day of your last period: *

Please use date format: DD/MM/YYYY

Have you missed any doses of your current oral contraception? *

Yes

No

Have you experienced any unusual vaginal bleeding in the last 2 years? *

Yes

No

When did this occur? *

Have you been pregnant in the last 2 months? *

Yes

No

Has anyone in your close family (mother/father/brother/sister) had heart attack under the age of 50, a blood clot in legs or lung or stroke? *

Yes

No

Are you taking any prescription/ herbal medicine eg. St John’s Wort? *

Yes

No

Have you ever had breast cancer? *

Yes

No

Have you ever had gastro-intestinal (bowel) or gallbladder problems? *

Yes

No

Please provide further details: *

Have you ever had liver problems or jaundice? *

Yes

No

Have you ever had a blood clot in legs or lung, a stroke or a heart condition? *

Yes

No

Have you ever had any other serious health conditions, illnesses, major surgery or medical treatment that we should know about? *

Yes

No

Please provide further details: *

Have you ever suffered from migraines or developed any since using the pill? *

Yes

No

Do you smoke? *

Yes

No

How many do you smoke per day? *

If you wish to discuss any alternative contraception methods, please contact the practice to arrange an appointment.

*

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

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Section

About You

Blood Pressure Reading

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