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Urban Village Medical Practice NHS GP Surgery in Ancoats

Contraceptive pill review

Contraceptive Pill Review

Section

Usual GP

Blood Pressure & Weight

If you do not have access to a blood pressure monitor or weighing scales, please ask to use them at reception.

Systolic “Higher”

Diastolic “Lower”

Weight

Your health

Please answer all the questions in this section.

Will you be 35 years or older within the next 12 months? *

Yes

No

Do you smoke? *

Yes

No

Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months?

Deep vein thrombosis (a blood clot in the veins of the leg)

Pulmonary embolism (a blood clot in the lungs)

Stroke or cerebro-vascular disease

Heart disease

Have you been diagnosed with or experienced any of the following conditions in the past 12 months?

Unexplained leg swelling

Chest pain that is worse when breathing deeply or unexplained shortness of breath

High blood pressure

High cholesterol

Diabetes

Liver disease

Gallbladder disease including gallstones

Epilepsy

Raynaud’s disease

Breast cancer

Are you currently taking any of the following medications?

Anti-epileptic medication

Rifampacin

St Johns Wort

Do you suffer from migraines with aura, or a headache associated with weakness or numbness on one side of your face or body, or difficulty with speech? *

Yes

No

A migraine is usually a severe headache felt as a throbbing pain at the front or on one side of the head. Some people experience a sensation, or aura, just before their migraine starts. Symptoms of aura include flashes of light or blind spots, difficulty focusing, and seeing things as if you are looking through a broken mirror. This is known as migraine with aura.

Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? *

Yes

No

Have you forgotten to take your pill on more than one occasion per month? *

Yes

No

Would you like to discuss ‘what to do in the event of a missed pill’ with you GP or practice nurse? *

Yes

No

Would you like to discuss long acting reversible contraception options with you GP or practice nurse? (Please see link on attached information sheet) *

Yes

No

Do you have any questions regarding your contraception or this questionnaire? *

Yes

No

Patient Declaration

I confirm that all of the information that I have provided on this form is correct at the time of completing the form.

I confirm that I will inform my GP should there be any changes to my health whilst I am taking oral contraceptive tablets.

Signature *

Date

Please note that the details you give will be used to update your medical records. If your correct contact information is not entered we will not be able to respond to you.

*

I confirm that the information provided is accurate to the best of my knowledge.

If you are human, leave this field blank.

Sending

Ancoats Primary Care Centre
Old Mill Street
Ancoats
Manchester
M4 6EE

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0161 272 5656

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