Contraceptive Pill Review


Contraception Pill Review

In Metres
Any current risk of pregnancy?
Are you currently breastfeeding?
Any personal or immediate family history (ie. Mum, Dad, Sister or Brother) of thrombosis (Blood clots), stroke, cardiovascular disease, breast cancer or diabetes?
Any personal history of thrombophlebitis, epilepsy or migraine (With or without aura)?
Are you currently sexually active?
Any problems with previous contraception?
Have you missed taking any of your contraceptives?
Do you know what to do if you do miss your contraceptive?
Do you regularly check your breasts?

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

Are you experiencing any irregular bleeding?

Blood Pressure


Smoking status: *
Would you like advice on how to quit? *

Please confirm that you are aware no contraceptive method is 100% (except abstaining from sexual activity) and that only barrier methods protect from sexually transmitted disease: *
Please confirm you understand that there are risks of taking oral contraceptives, you may experience side effects and that you understand these risks: *

Please call the practice to discuss the potential risk and side effects.