Annual Contraceptive Pill Review

For patients to complete, if this form is not completed accurately and in full, it will delay your prescription.

For patients who are currently taking a contraceptive pill, prescribed by Upwell Health Centre, who are happy with their current contraception and wish to continue taking it.

In order to provide the contraceptive pill safely, we need to ask you several questions. A blood pressure reading, weight and height taken within the last 4 weeks is also needed, this can be done with home devices or by using our health pod in the surgery waiting room.

If you are having any problems with your pill or would like to consider alternative contraception options, please contact the practice to arrange a telephone consultation with a clinician.

Contraceptive Pill Review

Contraceptive Pill Review

Section

Contraception Pill Review

In Metres
In KG
Do you regularly check your breasts?

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

Do you suffer from severe headaches or migraines?

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Have you developed new, unscheduled bleeding since your last pill review e.g. bleeding after sex, bleeding in between periods?

Please book an appointment to see the practice nurse

Do you smoke?
Would you like help giving up smoking?
Do you have any troublesome side effects from your contraceptive pill?
Do you currently have, or suffered in the past from, a blood clot, heart attack, stroke, breast or cervical cancer, liver or gallbladder disease?
Do you have a family history of blood clots or breast cancer?
Are you aware what to do if you miss a contraceptive pill?
Are you aware that the contraceptive pill may not work if you have diarrhoea and vomiting and the precautions you should take?
Are you aware of other forms of long acting contraception such as injection, implant and coils?
Are you aware the contraception pill does not protect you from sexually transmitted diseases, so you will need to use condoms to protect yourself?

Please visit www.sexwise.org.uk or request a telephone consultation with a clinician.

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?

Please read our Guide to Long-Acting Reversible Contraception page if you would like further information.

Blood Pressure

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

If you are unable to take your blood pressure at home, a blood pressure monitoring machine is available in our waiting room.

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