Contraceptive Pill Review FOR PATIENT TO COMPLETE, IF THIS FORM IS NOT COMPLETED ACCURATELY AND IN FULL IT WILL DELAY YOUR PRESCRIPTION Patient Name Date of birth DD slash MM slash YYYY Telephone Number What is your blood pressure? What is your height? What is your weight? *Skip if non smokerHow many ciggarettes do you smoke per day? Optional Would you like help with quitting? Optional Do you have any troublesome side effects from your contraceptive pill? Yes No If yes, Please state Have you developed new, unscheduled bleeding since your last pill review e.g. bleeding after sex, bleeding in-between periods? Yes No Do you currently have, or suffered in the past from, a blood clot, heart attack, stroke, breast or cervical cancer, liver or gallbladder disease? Yes No if yes, please state Optional Do you have family history of blood clots or breast cancer? Yes No Are you aware of the following?A) what to do if you miss a contraceptive pill? Yes No B) That the contraceptive pill may not work if you have diarrhoea and vomiting and the precautions you should take? Yes No C) Of other forms of long acting contraception such as injection, implant and coils? Yes No D) The contraception pill does not protect you from sexually transmitted diseases, so you will need to use condoms to protect yourself? Yes No Would you like to book a telephone consultation with a clinician to discuss any concerns you have with your contraceptive pill or to discuss alternative forms of contraception? Yes No
