Combined Oral Contraception Pill Review

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

For more information, please read the NHS guidance on oral contraception.

Combined Oral Contraception Pill Review

Combined Oral Contraception Pill Review

Are you over the age of 16? *

Please use our Request an appointment with a Nurse or Assistant Practitioner form to book an appointment.

Section

Review

eg. 1.75
eg. 60.6
Do you regularly check your breasts?

Please read the information from the NHS regarding the importance of breast examination.

Do you suffer from severe headaches or migraines?

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

Are you experiencing any irregular/unusual/breakthrough bleeding?

Please make an appointment to see a nurse.

Are you currently sexually active?
Can you provide a recent blood pressure reading? *
Blood Pressure Reading:

Please make an appointment with the Practice Nurse to take your blood pressure.

Smoking Status: *
Do you wish to give up smoking? *

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what’s right for you. For more information visit the Smokefree website.

Are you taking any other medication (including over the counter medication)?
Do you have any relevant medical history (epilepsy, H/O clotting, breast cancer)?
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Have you missed or taken your contraceptive pill late?
Have you ever had a cervical smear?
Please use this date format: DD/MM/YYYY

Please visit the following website for information and advice on cervical screening:

www.nhs.uk/conditions/cervical-screening

Contraceptive pills do not protect against sexually transmitted infections, condoms are the only type of contraception that can both prevent pregnancy and protect against sexually transmitted infections (STIs). For more information, please visit www.nhs.uk/conditions/contraception/male-condoms

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