Oral Contraceptive Pill Check

Date of Birth
In Metres
Form will be discarded and not submitted for review if blood pressure not completed accurately

Contraception Pill Review

Smoking status
Do you suffer from severe headaches or migraines?
Have you or anyone in your immediate family had a stroke, pulmonary embolism or deep vein thrombosis under the age of 45 years?
Do you regularly check your breasts?
Do you have any personal or family history of breast cancer?
Are you experiencing any irregular/unusal bleeding?
Has anything changed in your medical history since your last review?
Do you have any problems remembering to take your pill?
Are your cervical smears up to date?
Do you wish to discuss the method or anything else related to your contraception or sexual health with a nurse?