Oral Contraceptive Pill Check Name First Last Date of Birth Day Month Year PhoneEmail Enter Email Confirm Email HeightIn Metres WeightIn KG Systolic Blood Pressure "Higher"Form will be discarded and not submitted for review if blood pressure not completed accuratelyDiastolic Blood Pressure "Lower"Contraception Pill ReviewSmoking status Never smoked Ex-smoker Smoker Do you suffer from severe headaches or migraines? Yes – But the Doctor is unaware Yes – But the Doctor is aware No Have you or anyone in your immediate family had a stroke, pulmonary embolism or deep vein thrombosis under the age of 45 years? Yes No Do you regularly check your breasts? Yes No Do you have any personal or family history of breast cancer? Yes No Are you experiencing any irregular/unusal bleeding? Yes No Has anything changed in your medical history since your last review? Yes No Do you have any problems remembering to take your pill? Yes No Are your cervical smears up to date? Yes No Do you wish to discuss the method or anything else related to your contraception or sexual health with a nurse? Yes No I confirm that the information provided is accurate to the best of my knowledge
