Contraceptive Pill Review

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

Please read the Contraceptive Pill Review Information page before completing this form.

Advice about long acting reversible contraception

Contraceptive Pill Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Your Blood Pressure


Smoking Status *
Are you interested in Cessation advice?

If you would like help in quitting, please visit SmokeFree Hampshire is a free NHS sevice helping poeple who want to stop smoking.

Contraception Pill Review

Are you aware of how the pill works?
Are you aware of what to do if you miss a pill?
Are you aware that the contraceptive pill does not protect you from Sexually Transmitted Infections (STI), so you will need to use a condom as well to protect yourself?

To order a STI testing kit online please visit

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.

Do you suffer from visual symptoms or changes in sensation or muscle power on one side of your body?
Have you or your parents or siblings been diagnosed with heart disease or stroke under the age of 45??
Do you have diabetes?
Have you or any family member under the age of 45 had a deep vein thrombosis or pulmonary Embolus (Blood clot in the leg or lung)?
Do you have any blood clotting illnesses/ abnormalities?
Do you have any personal or family history of breast cancer under the age of 50?
Do you regularly check your breasts?

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

Are you aware of the alternatives such as long active reversible contraceptives?
Would you like to book a consultation with a doctor to discuss or arrange fitting a long acting reversible contraceptive?
Are you experiencing any irregular bleeding?

Please book an appointment to see the practice nurse

Please note that the details you give will be used to update your medical records.