Contraceptive Pill Review

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Contraceptive Pill Review 

If you have been advised by the practice to submit a contraceptive pill review please complete and submit this form.


All questions marked with a * are mandatory

Personal Details
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Contraception Pill Review
Have you had any recent changes in your health that might affect your contraception?: *
Have you ever had a blood clot in your legs or lungs (deep vein thrombosis or pulmonary embolus)? : *
Do you have any blood clotting abnormalities?: *
Do you have parents or siblings who have ever been diagnosed with a blood clot in their legs or the lungs (deep vein thrombosis or pulmonary embolus)?: *
Do you have parents or siblings who have had heart disease or strokes under the age of 55? : *
Do you have parents or siblings who have had breast cancer under the age of 50?: *
Have you given birth within the last 6 weeks?: *
Do you suffer from severe headaches or migraines? : *
Are you experiencing any irregular vaginal bleeding? : *

Book an appointment to see a GP

You cannot continue with this form: *
Do you currently smoke or have you stopped smoking in the last year?: *
Blood Pressure

If you do not have a machine at home, please come to reception and have your blood pressure and weight measured on the practice machine.

Higher number
Lower number

Book an appointment to see a GP

As your Blood Pressure is over 140/90 this needs to be reviewed

You cannot continue with this form: *
Body Mass Index
Blood Pressure

How to calculate your Body Mass Index (BMI)

Contraceptive Pill

Effectiveness of the pill

  General advice on the pill including different ways to take it

  What to do if you miss a pill


Some medication can reduce the effectiveness of ‘the pill’

  • Always check with the pharmacist or prescriber if you are taking any new medication or suppliments 
  • this includes St John’s wort which you should avoid
Stop Smoking

Longer acting forms of contraception

Long-acting reversible contraception is contraception that doesn't depend on you remembering to take or use it to be effective.

  More information

Would you like to consider longer acting forms of contraception that may not need you to remember to take your pill every day?: *

How to get a longer acting form of contraception

If you would like a contraceptive implant, intra uterine device or contraceptive injection, please arrange to speak with a Nurse


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