Contraceptive Pill Review

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

Contraceptive Pill Review

Contraceptive Pill Review

Section

Please select one option for the pill type: *

Combined Pill

Do you know the name of the contraceptive pill that you want?
Have you started taking any new regular medications or health supplements (e.g. St John's Wort) recently?
Have you been diagnosed with any new health conditions since we last issued you a prescription for the pill? These could be any conditions but in particular: heart disease, stroke, breast cancer, liver disease.

To ensure prescribing the pill is safe, please answer the following questions about medical issues that you may have or that run in your family.

Are you getting new or worsening headaches?
Do you get migraines?
A migraine is usually a moderate or severe headache felt as a throbbing pain on one side of the head. For more information about migraines, see patient.info/brain-nerves/migraine-leaflet
Do you have an aura with your migraines?
An aura is where you have warning signs before your headache begins such as changes to your vision or numbness/pins and needles
Have you ever had a blood clot (also known as DVT/PEs)?
These are clots that cause swollen and painful arms, legs or chest pain. For more information about blood clots, see patient.info/allergies-blood-immune/deep-vein-thrombosis-leaflet
Have any of your immediate family ever had a blood clot (DVT/PE)?
Your immediate family includes your father, mother, brother and sister
Have any of your immediate family or second degree relatives ever had breast cancer?
Your immediate family include your father, mother, brother or sister. Your second degree relatives include your aunts, uncles, nephews, nieces, grandparents and grandchildren
Do you have any new unexpected bleeding between your periods since your last review?
Do you have any new bleeding after sex since your last review?
Are you up-to-date with your cervical screening (smear test)?
Are you interested in having any sexual health screening?
This could be important as the oral contraceptive does not protect against sexually transmitted infections
What is your smoking status?
How much do you smoke?

Smoking leads to health problems such as cancer, heart disease and strokes. The benefits of stopping smoking include: better health, more money and cleaner air for those around you!

Do you want to stop smoking? Here is some advice on ways to quit smoking, local services and general tips: NHS Smokefree

Are you able to provide a blood pressure reading? To safely prescribe the contraceptive pill, it is important that we have an up-to-date blood pressure reading.

Before you take your blood pressure reading:

  • Sit down comfortably for 5 minutes.
  • Wear loose-fitting clothing.
  • Make sure your arm is around the same level as your heart.
  • Make sure your arm is relaxed.

When taking your blood pressure:

  • Put the cuff on following the instructions which came with your blood pressure monitor.
  • Keep still and silent.

Other tips:

  • Take at least three readings, each two minutes apart.
  • Your first reading may be much higher than the next readings. If this is the case, keep taking readings until they level out and stop falling. Use this as your reading.

Please seek urgent medical attention if you develop any of the following:

  • Blood pressure is 180/110 or above (despite repeating it at least 2 times)
  • Chest pain
  • Changes in vision
  • Confusion
  • Severe headache

British Heart Foundation: How to take your reading

Do you know your weight?
If you only know your weight in stone and pounds, please use the Measurement Converter.
Do you know your height?
If you only know your height in feet and inches, please use the Measurement Converter.
Are you having any side effects or problems from your contraceptive pill that you would like to discuss with your GP/nurse?

Progestogen-only pill

Do you know the name of the contraceptive pill that you want?
Have you been diagnosed with any new health conditions since we last issued you a prescription for the pill? These could be any conditions but in particular: heart disease, stroke, breast cancer, liver disease.
Have you experienced any changes to your bleeding pattern that are worrying you (such as unexpected spotting, or after sex)?
Are you up-to-date with your cervical screening (smear test)?
Are you interested in having any sexual health screening?
This could be important as the oral contraceptive does not protect against sexually transmitted infections
What is your smoking status?
How much do you smoke?

Smoking leads to health problems such as cancer, heart disease and strokes. The benefits of stopping smoking include: better health, more money and cleaner air for those around you!

Do you want to stop smoking? Here is some advice on ways to quit smoking, local services and general tips: NHS Smokefree

Are you able to provide a blood pressure reading? To safely prescribe the contraceptive pill, it is important that we have an up-to-date blood pressure reading.

Before you take your blood pressure reading:

  • Sit down comfortably for 5 minutes.
  • Wear loose-fitting clothing.
  • Make sure your arm is around the same level as your heart.
  • Make sure your arm is relaxed.

When taking your blood pressure:

  • Put the cuff on following the instructions which came with your blood pressure monitor.
  • Keep still and silent.

Other tips:

  • Take at least three readings, each two minutes apart.
  • Your first reading may be much higher than the next readings. If this is the case, keep taking readings until they level out and stop falling. Use this as your reading.

Please seek urgent medical attention if you develop any of the following:

  • Blood pressure is 180/110 or above (despite repeating it at least 2 times)
  • Chest pain
  • Changes in vision
  • Confusion
  • Severe headache

British Heart Foundation: How to take your reading

Do you know your weight?
If you only know your weight in stone and pounds, please use the Measurement Converter.
Do you know your height?
If you only know your height in feet and inches, please use the Measurement Converter.
*
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