Contraceptive Pill Review Form Contraceptive Pill Review Form If you have been advised by the surgery to submit a contraceptive pill review please use this form. Your DetailsName DrMissMrMrsMsProf.Rev. Prefix First Last Nominated Pharmacy OptionalDate of Birth DD slash MM slash YYYY Phone Number OptionalEmail Address Contraceptive Pill ReviewThis form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. * I consent to the practice collecting and storing my data from this form. What is the current pill that you are taking? OptionalIf you have checked your blood pressure, please tell us the reading and the date this was taken (if you have not have your blood pressure checked within the last 12 months, please arrange for this to be checked before your next prescription is due) OptionalSmoking StatusPlease select an answerNon smokerCurrent smokerEx smokerIf you are a smoker, how many do you smoke a day? Would you like help to stop smoking? OptionalHow many units of alcohol do you normally drink each week on average?If you drink more than 14 units per week, would you like to discuss your drinking habits further and seek advice and support? OptionalWhat is your current weight?What is your current height?If you know your BMI and it is over 25, would you like support and advice about weight management? Yes Optional No Optional How much exercise do you normally do on average each week? (Please state the type of exercise)Please confirm that the information provided has been provided by the patient named on the form? Yes No Are you happy with you current pill or do you wish to discuss and alternative contraception? Yes No Have you previously discussed alternative choices of contraception and the possible risks with a health professional? No Yes Do you know what to do if you miss a pill? Yes No Do you ever suffer with migraines or headaches? (please state when they started, how often/severe they are and if they are accompanied with visual disturabnces) OptionalHave you ever been advised that you have had a blood clot such as Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)? OptionalPlease select an answerNoDVTPEDo you have a 7-day break on your current pill regime? Yes No Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? No Yes Have you noticed any new and unusual vaginal discharge? Yes No Have you had any new partners recently? Yes Optional No Optional Do you examine your breasts regularly to detect for any lumps? Yes No Do you have any family history of breast cancer, heart disease or strokes? (Please state who and what ages they were if known)