Contraceptive Pill Review

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

Contraceptive Pill Review

Contraceptive Pill Review

Contraception Pill Review

How long have you been taking this pill? *

(If it is desogestrel/minipill then you do not need to fill the form).

Are you happy to use the Electronic Prescription Service?
Have you had any problems with your current pill or are you unhappy with it? *
Have you ever had any kind of migraine? *
(i.e. a severe headache with a dislike of noise or light, visual disturbances or sickness)
Are you experiencing any irregular bleeding? For example, after sex. *

Please book an appointment to see the practice nurse

Have you had any episodes of DVT (deep vein thrombosis) or blood clot in your leg or lung? (i.e. a clot requiring blood thinning medication, such as warfarin or rivaroxaban) *
Has any of your immediate family had a DVT/blood clot to legs or lungs? *
Has any of your immediate family had a DVT/blood clot to legs or lungs? *
Do you have a family history of breast cancer? *
Have you ever had problems with your liver? *
Have there been any changes to your health since you were last seen? *
Are you taking St John’s Wart (an herbal anti-depressant) or any other medication we are not aware of? *

Your Observations

Do you, or have you ever, smoked? *
Would you like smoking cessation advice?

About You

In Metres
mmHg (home measurements from reputed arm BP monitor are acceptable

If your readings are either above 140 systolic (top number) or above 90 diastolic (bottom number), please repeat two more times.


Do remember that there are lots of different contraceptive options available, including pills, injections, implants and coils, please consult: for advice on making the right choice for you.

Further information, including guidance on what do in the case of missed pills or sickness, can be found at:

I hereby declare that the information I have supplied on this form is true and correct to the best of my knowledge.

Your prescription should be ready within 5 working days, unless you hear from us to book an appointment.