Contraceptive Pill Review

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

Please only complete this form if asked to by a clinician.

Contraceptive Pill Review

Contraceptive Pill Review

Registered practice: *


Contraception Pill Review

Any current risk of pregnancy? *
Are you currently breastfeeding? *
Any personal or immediate family history (ie Mum Dad Sister or Brother) of thrombosis (Blood clots), stroke, cardiovascular disease, breast cancer or diabetes? *
Any personal history of thrombophlebitis, epilepsy or migraine (With or without aura)? *
Are you currently sexually active? *
Any problems with previous contraception? *
Have you missed taking any of your contraceptives? *
Do you know what to do if you do miss your contraceptive? *
Do you regularly check your breasts? *

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

Are you experiencing any irregular bleeding? *

Blood Pressure


Smoking Status: *
Would you like advice on how to quit? *

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

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