Oral Contraceptive Pill Proforma



SECTION 1

Are you currently taking the oral contraceptive pill?

Have you noticed any side effects?

Are you currently taking any medication or have you recently finished a course of any medication?

Do you have any drug allergies?

SECTION 2

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 (e.g. with your eyes, kidneys or sensation in your hands/feet)?

Have you ever had any form of cancer (e.g. breast, liver)?

Have you or anyone in your family ever had blood clots (e.g. 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)?

SECTION 3

Do you smoke?

Have you had a blood pressure check in the last 12 months?

Please note – We will be unable to issue the medication without an up to date blood pressure reading. If you do not have access to a blood pressure monitor at home there is one available for public use in the information area at the Frome Medical Centre.

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?

By clicking submit I confirm and agree that any treatment prescribed for me is for my personal use only and that all of the information provided is accurate and correct.



If there any issues we need to discuss then you will contacted on the number provided

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More about your health and wellbeing

Have you considered long-term reversible contraception? For example coils/contraceptive injection/contraceptive implants. Please see the linked information sheet".

If you would like to discuss an alternative method of contraception please make an appointment with the family planning clinic via the Frome Medical Practice Website or Tel: 01373 301301

Hormonal contraception does not protect against sexually transmitted infections (STI).

What are sexually transmitted infections? http://patient.info/health/sexually-transmitted-infections-leaflet

Did you know that it is estimated 1 in 7 sexually active people under the age of 25 has chlamydia?

You can pick up a completely confidential and free chlamydia self-test kit from the boxes placed in the communal areas throughout the practice.

Do you know how to access sexual health services locally? Please see this link.

Are you up to date with your cervical smear? Women aged 25-49 receive invitations every 3 years and women aged 50-64 receive invitations every 5 years. For more information please see this link .