Contraceptive Pill Review Contraceptive Pill Review If you are human, leave this field blank. Patient Details Full Name: * Date of Birth: * Please use this date format: DD/MM/YYYY. Phone Number: Email Address: * Any responses we send will go to this email address. 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 Meters): * e.g 1.75 Weight (in Kilograms): * e.g 60.6 BMI: 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. Contraception Pill Review 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 - But the Doctor is unaware Yes - But the Doctor is aware No Please make an appointment to see your doctor to discuss your headaches if you have not already done so. Do you smoke? * Yes No How many do you smoke per day? * Name of current contraceptive pill: Do you regularly check your breasts? Yes No Please ask reception for our information regarding the importance of regular breast self-examination. 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