Contraceptive Pill Review

If you have been advised by the surgery to submit a contraceptive pill review please use this form.

Contraceptive Pill Review

Contraceptive Pill Review

About You

In Metres
In KG

Smoking Status

Do you currently smoke?
Have you smoked in the past?
How many cigarettes did you smoke in a day?
How many cigarettes do you smoke in a day?
Would you like to give up smoking?

Smoking cessation support is available at the practice, through local pharmacies and via the NHS website.

If you would like to consider giving up smoking in future, please contact the surgery who will be able to offer support.

Contraception Pill Review

Do you regularly check your breasts?

Please ask reception for our information regarding the importance of regular breast self-examination.

Do you suffer from severe headaches or migraines?

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Are you experiencing any irregular bleeding?

Please book an appointment to see the practice nurse

*