Yearly Contraceptive Review

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number: *

Email Address: *

Health Questionnaire

Height:

Weight:

BMI:

Please leave blank if unknown.

Smoking Status: *

Non-smoker

Ex-smoker

Current smoker

How many cigarettes a day:

If you smoke, we strongly advise you to stop. If you would like help with this, please speak to reception about our in-house clinic.

Do you drink alcohol:

Yes

No

Number of units per week:

(1 unit = small glass of wine or half pint beer)

Please enter a recent blood pressure reading:

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Contraception Questionnaire

Name of your current contraception: *

Eg. Microgynon Pill, IUD Coil etc.

If over 25, have you had a smear test in the last 3 years?

Yes

No

Please book in at reception to book your next smear test.

Do you have a history of migraines or severe headaches?

Yes

No

Do you have problems with forgetting to take your pills?

Yes

No

We will contact you to discuss this.

Have you ever had a stroke, a blood clot in your legs or your lungs, a heart attack or any heart problems?

Yes

No

Has your mother, father, brother or sister had a blood clot in their legs or lungs aged under 60 years?

Yes

No

Has your mother, father, brother or sister had a heart attack or stroke aged under 60 years?

Yes

No

Have you or any family member had womb or cervical cancer?

Yes

No

Have you, or anyone in your family, had cancer of the breast?

Yes

No

Do you self-examine your breasts regularly?

Yes

No

Have you been given information about long acting reversible contraceptives (implants, coils, injections)?

Yes

No

If you would like more information, please see www.fpa.org.uk, or book to discuss these options with our pharmacist/doctor.

Would you like a sexual health screen? Please see www.royalberkshire.nhs.uk/florey-sexualhealth for further details.

Informed Consent

I have answered the above questions to the best of my knowledge and am aware of the risks to my health if the information provided is inaccurate.

I am requesting this medication for my sole use only and not on the behalf of another person.

I know that missing pills or having severe diarrhoea and /OR vomiting may stop the pill from working effectively and I will need to follow advice in the patient leaflet or contact a doctor for further advice.

I know that if I experience any unexplained pain or swelling in legs or unexplained chest pain or shortness of breath or abnormal vaginal bleeding or migraines to contact my doctor for further advice.

Signature: *

Date:

South Reading Surgery

Shinfield Health Centre