Contraceptive Pill Review – Break

This form is not to be used for any emergency health problems. It is for review purposes only.

Due to the current crisis we may take a little longer to deal with requests, we aim to deal with any queries as soon as possible, prescriptions and sick notes will be issued within 5 days and backdated where required.

Is this the right review form for you? Please note that there are separate forms for Asthma, COPD, the contraceptive pill and medication reviews. Please ensure that you complete the correct form.

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

Contraception Pill Review

Smoking Status *
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 Missed Pill Rules? *
Do you take any over the counter medication that we may not be aware of? *
Has there been any changes in your personal and/or family history in terms of blood clots to the legs (DVT) or lungs (PE) or stroke or breast cancer?
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