Contraceptive Pill Review

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

If you are human, leave this field blank.

Height *

In Metres

Weight *

In KG

Do you regularly check your breasts? *

Yes

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

Do you suffer from severe headaches or migraines? *

Yes - But the Doctor is unaware

Yes - But the Doctor is aware

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? *

Yes

Please book an appointment to see the practice nurse

I confirm that the information provided is accurate to the best of my knowledge

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