Contraceptive Pill Checklist (for women 20 years and older)

In order to provide the contraceptive pill safely we need to ask you a number of questions. We would be grateful if you could complete this form when you submit your next repeat prescription request.
If you are having any problems with your medication or would like to consider alternative contraception options, please speak to one of our Practice nurses, who will be able to advise you, or refer you to the Doctor as appropriate.

Contraceptive Pill Checklist (for women 20 years and older)

Patient Details

Please use format DD/MM/YYYY
Please provide the best number to contact you on if we have any queries.
Please use format:

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).