Contraceptive Pill Review Form Contraceptive Pill Review Form If you have been advised by the surgery to submit a contraceptive pill review please use this form. Name First Last Please enter your full legal nameDate of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please enter your Date of Birth in the format DD/MM/YYYYPhone OptionalEmail Address Contraceptive Pill ReviewPlease complete the form belowWill you be 35 years or older within the next 12 months? Yes No Weight OptionalPlease enter how much you weighSmoking Status Smoker Ex-Smoker Non-Smoker Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months? Deep vein thrombosis (a blood clot in the veins of the leg) Optional Pulmonary embolism (a blood clot in the lungs) Optional Stroke or cerebro-vascular disease Optional Heart disease Optional Have you been diagnosed with or experienced any of the following conditions in the past 12 months? Unexplained leg swelling Optional Chest pain that is worse when breathing deeply or unexplained shortness of breath Optional High blood pressure Optional High cholesterol Optional Diabetes Optional Liver disease Optional Gallbladder disease including gallstones Optional Epilepsy Optional Raynaud’s disease Optional Breast cancer Optional Are you currently taking any of the following medications? Anti-epileptic medication Optional Rifampacin Optional St Johns Wort Optional 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 Have you forgotten to take your pill on more than one occasion per month? Yes No Would you like to discuss 'what to do in the event of a missed pill' with you GP or practice nurse? Yes No Would you like to discuss long acting reversible contraception options with you GP or practice nurse? Yes No Consent I consent to the practice collecting and storing my data from this form.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.