Contraceptive Pill Review

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

Please read our Important Information For Women Regarding Blood Clots page.

Contraceptive Pill Review

Contraceptive Pill Review


Contraception Pill Review

In Metres

Blood Pressure


Additional Information

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.

Do you experience visual symptoms or changes in sensation or muscle power on one side of your body at these times?
Do you have regular bleeds in your pill-free (or patch-free) interval?
Are you ever late restarting after the pill-free (or patch-free) interval?
Do you bleed in between these bleeds or after sex at all?
Do you remember to take your pill every day/change your patch weekly?

Important Information

You may benefit from reading about long-acting reversible contraception at

If you are unaware how the pill works, what to do if you are late or miss a pill or are unwell with diarrhoea and/or vomiting or just want to consider other contraceptive options, please visit for further information or request an appointment to discuss with Nurse Julie or Debbie.

There are a variety of options regarding how you take your pill and if and when you have a pill-free break. Please visit for more information; select combined pill and see page 9. Further information can be found on the practice website.


Smoking Status: *
Are you interested in advice on how to quit?

Smoking Cessation services are available on 0800 0854 113.

Medical History

Have there been any recent changes to your health that we may not know about?
Please include dates.
Are you taking any medicines from ‘over the counter’?
Is there any family history under the age of 50yrs of any of the following:

Important Information

If you have had a change of sexual partner(s) in the past 1 year, it may be beneficial to consider a chlamydia test.

If you are under 25yrs you can request a test from or collect from reception. Details regarding free condoms can also been found on their website.

If you are over 25yrs, make an appointment to discuss with Nurse Julie or Debbie.