Contraceptive pill review

Section

Contraception Pill Review

Current weight: *

Date of last menstruation: *

Any current risk of pregnancy? *

Yes

No

Are you currently breastfeeding? *

Yes

No

Any personal or immediate family history (ie Mum Dad Sister or Brother) of thrombosis (Blood clots), stroke, cardiovascular disease, breast cancer or diabetes? *

Yes

No

Please specify: *

Any personal history of thrombophlebitis, epilepsy or migraine (With or without aura)?

Yes

No

Please specify: *

Are you currently sexually active? *

Yes

No

Any problems with previous contraception?

Yes

No

Have you missed taking any of your contraceptives?

Yes

No

Do you know what to do if you do miss your contraceptive?

Yes

No

Do you regularly check your breasts?

Yes

No

Please ask reception for our information regarding the importance of regular breast self-examination.

Are you experiencing any irregular bleeding?

Yes

No

Blood Pressure

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Smoking

Smoking Status: *

Current Smoker

Ex Smoker

Never Smoked

How many do you smoke per day? *

Would you like advice on how to quit?

Yes

No

How many did you smoke per day? *

When did you quit smoking? *

Please confirm that you are aware no contraceptive method is 100% (except abstaining from sexual activity) and that only barrier methods protect from sexually transmitted disease:

Yes

No

Please confirm you understand that there are risks of taking oral contraceptives, you may experience side effects and that you understand these risks:

Yes

No

Please call the practice to discuss the potential risk and side effects.

I confirm that the information provided is accurate to the best of my knowledge and that I have been asked to complete this form by a clinician

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Section

Contraception Pill Review

Blood Pressure

Smoking