Contraceptive pill review

About you

Height (in Metres):

eg. 1.75

Weight (in Kilograms):

eg. 60.6

BMI:

Blood pressure

Please provide a blood pressure reading if you have access to a machine.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Smoking

Smoking status: *

Smoker

Never smoked

Ex smoker

Smoker

What do you mainly smoke?

How many cigarettes do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco do you smoke per week? *

Pipe – How many grams of tobacco do you smoke per week? *

Would you like to give up smoking? *

Yes

No

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex smoker

What did you mainly smoke?

How many cigarettes did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco did you smoke per week? *

Pipe – How many grams of tobacco did you smoke per week? *

When did you give up smoking? *

Review

Do you regularly check your breasts?

Yes

No

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

Do you have normal periods (menstruation)? i.e. a regular cycle with no excessive or intermenstrual bleeding *

Yes

No

Please describe your cycle:

Absence of menstruation (No bleeding)

Infrequent menstruation

Intermenstrual bleeding

Irregular or variable cycle with normal bleeding

Irregular or variable cycle with excessive/heavy bleeding

Regular cycle with excessive/heavy bleeding

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

Do you know how to take your medication properly? *

Yes

No

Please specify any side effects you are having with your medication:

Have you suffered from severe headaches or migraines in the past 3 months?

Headaches

Migraines

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

Terms and conditions

I confirm that this is not an emergency and understand the surgery cannot help while it is closed. If I need help right now, I will use the NHS 111 service. In an emergency, I will call 999 or go to A&E.