Contracteptive Pill Review Form - Mountsandel Medical Centre

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

Weight - KG *

HEIGHT - IN CMS *

Smoking Status *

Smoker

Ex-Smoker

Non-Smoker

Vape

Blood pressure and date taken? *

Do you have a family history of Breast Cancer in your immediate family, under the age of 50? (mum, dad, brothers or sisters) . *

Yes No

DO YOU HAVE A PARENT OR SIBLING WHO HAS HAD A DVT OR PULMONARY EMBOLISM UNDER THE AGE OF 45? *

Yes No

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

Unexplained leg swelling

High blood pressure

Diabetes

Breast cancer

DVT (blood clot in leg)

Pulmonary Embolism (blood clot in lung)

Heart Attack

Stroke

None of the above

IS YOUR MOBILITY SIGNIFICANTLY REDUCED(E.G. REQUIRING A WHEELCHAIR OR CRUTCHES)?? *

Yes No

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

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

Yes No

Are you happy to continue with your current prescription? If not please book a routine call to discuss with the the GP. *

Yes No

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

Combined Contraceptive Pill and Patch Review Form

Combined Contraceptive Pill and Patch Review Form

Further Information