Contraceptive Pill Checklist (for women 20 years and older)

Section

About Your Health

Are you able to provide a home blood pressure reading? *

Please arrange a practice nurse appointment for a BP check.

Are you a smoker?
Would you like help giving up?
Weight Unit:

About the Pill

Are you aware how the pill works?
Are you aware of what to do if you miss a pill?
Are you aware that the contraception may not work if you have diarrhoea or vomiting?
Are you aware that the contraceptive pill does not protect you from Sexually Transmitted Infection (STI), so you will need to use a condom as well to protect yourself?

Your Medical History

Do you suffer from migraines?
Do you suffer from visual symptoms or changes in sensation or muscle power on one side of your body?
Do you have parents or siblings who have had 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 PulmonaryEmbolus (blood clot in the leg or lung) ?
Do you have blood clotting illnesses/ abnormalities?
Do you have any family history of breast cancer under the age of 50?
Are you aware of the alternatives such as long acting reversible contraceptive?
Would you like to book a consultation with a doctor to discuss or arrange fitting a long acting reversible contraceptive?

Please remember cervical smear testing (every 3 years for women aged 25-50 and every 5 years for women aged 50-65).

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