Contraceptive Pill Review

Registered practice: *

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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