Pill Check

Patients who are 16 years old and over and taking a contraceptive pill provided by ourselves may no longer be required to attend for a pill check appointment. We now use a questionnaire for patients to order their contraceptive pill repeat prescription. We require an up to date height, weight and blood pressure (BP) in order to issue the prescription. These can be measured at home. Lots of people now have their own BP machine, have a family member who they can borrow one from or have the ability to check their BP at work. However if you have no access to a machine to check your BP then please contact the surgery and we will arrange to have your BP checked at the surgery. In order to provide the contraceptive pill we need to ask you a number of questions. We would be grateful if you could complete this form when you submit your next pill request. If you are having problems with your pill or would like to consider alternative contraception then please make it clear on the form and a follow-up appointment will be made for you. fields.

Oral Contraception Questionnaire

Date of Birth(Required)
International and (###) ### #### format available. Should restrict to International or remove from builder.
International and (###) ### #### format available. Should restrict to International or remove from builder.

About Your Pill

(Occasionally the brand name of your pill will need to be changed at a review due to stock/costing issues. We will inform you by text/email if we do have to make this change)
(eg every day/ or for 21 days and then a 7 day break/ or take 3 packets back to back and then 4-7 day break)
I consent to and would prefer to be contacted by (please tick as appropriate)(Required)

Your Health

Do you smoke?(Required)
Do you want help giving up smoking?
Are you aware of how the pill works?(Required)
Are you aware of what to do if you miss a pill?(Required)
Are you aware that the contraceptive pill may not work if you have diarrhoea or vomiting?(Required)
Are you aware of the different pill taking regimes available for pills containing oestrogen, the combined pill?(Required)
Are you aware that the contraceptive pill does NOT protect you from sexually transmitted infections, so you will need to use a condom as well to protect yourself?(Required)
Do you have epilepsy?(Required)
Do you suffer from migraines?(Required)
If you suffer from migraines do you experience visual symptoms or changes in sensation or muscle power on one side of your body?
Do you have parents or siblings who have had heart disease or strokes under the age of 45?(Required)
Do you have diabetes?(Required)
Have you had a deep vein thrombosis or pulmonary embolism?(Required)
Do you have parents or siblings that have had a deep vein thrombosis or pulmonary embolus under the age of 45?(Required)
Do you have any blood clotting illnesses / abnormalities?(Required)
Do you have any family history of breast cancer under the age of 50?(Required)
Are you aware of the alternatives such as long acting reversible contraception?(Required)
Would you like to be added to the waiting list for a consultation with a clinician to discuss or arrange fitting of a long acting reversible contraceptive or any other problems with your contraception?(Required)
Consent

Date published: 17th April, 2024
Date last updated: 17th April, 2024