Contraceptive Pill Check

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Personal Details

If you have been advised by the surgery to submit a contraceptive pill review please use this form.
Please be aware that we will require a blood pressure reading to complete your review.

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Contraceptive Pill Review
Are you currently taking the oral contraceptive pill?: *
Have you noticed any side effects?: *
Are you currently taking any other medication or have you recently finished a course of any medication?: *
Do you have any drug allergies?: *

This form is intended for patients who are already taking the Oral Contraceptive Pill already but need to have a review.

If you would like to start taking the Oral Contraceptive Pill please contact the practice on 01373 301301 to book an appointment with a practice nurse.

You are unable to continue with this form.: *
Health Questions

Your Height

What unit of measurement are you using?: *
Conversion from Feet & Inches to Centimetres

Your Weight

What unit of measurement are you using?: *
Conversion from Stones & Pounds to Kilograms
Do you suffer from migraines?: *
Do you ever get severe headaches at the front/side of your head, with nausea/vomiting, increased sensitivity to light or sound?: *
Have you ever had a heart attack, stroke, or high cholesterol?: *
Do you have problems with your kidneys or liver?: *
Including hepatitis, tumours
Do you have any complications from diabetes?: *
For example: with your eyes, kidneys or sensation in your hands/feet
Have you ever had any form of cancer?: *
Have you or anyone in your family ever had blood clots (like DVT or PE); or have you had major surgery in the last 3 weeks?: *
Do you have any other health problems you think we should know about?: *
Such as Lupus, unexplained vaginal bleeding

An annual Blood Pressure check is mandatory as to ensure the safe prescribing of hormonal contraception.

There is a Blood Pressure machine in the reception area at Frome Medical Practice which you can use during opening hours.

Have you ever suffered from high blood pressure, including during a pregnancy?: *
Are you pregnant or trying to become pregnant?: *
Have you given birth in the last 3 weeks?: *
Are you currently breastfeeding?: *
Have you ever smoked?: *
Do you smoke now?: *

We advise everyone to stop smoking. 

If you would like help to stop smoking please visit Healthy Somerset - Smoke Free for support to quit.

Is there a family history of breast cancer?: *

Privacy Consent


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