Home > Oral Contraception review

Oral Contraception review

Please complete the following questions to allow your health care professional to assess your current contraception. This questionnaire is for a routine review of your use of contraception. If you are experiencing any of the following ring your GP immediately:

Unusual or severe headaches
A faint or collapse
Migraines that are worse than normal
Painful swelling of your leg
Weakness or numbness of an arm or leg
Sudden problems with your speech or sight
Difficulty breathing
Coughing up blood
A bad pain in your tummy (abdomen)
Pains in your chest, especially if it hurts to breathe in

Please select the practice location most relevant to this Online Form submission:

Name

Date of BirthPlease enter Date of Birth as DD/MM/YYYY

Address

Your Contraception

1. What is your current weight?

2. What is your current height?

3. What is your current heart rate/pulse rate?

4. What is your Systolic blood pressure?(The larger number)

5. What is your diastolic blood pressure?(The smaller number)

6. Have you been experiencing side effects since taking the pill?

Yes

Unsure

7. If yes, please provide details of the side effects you have been experiencing:

8. Do you currently experience or have a history of Migraines?

Yes

9. Have you ever had any blood clots?(e.g Deep vein thrombosis or pulmonary embolism)

Yes

10. Have you ever had a heart attack or stroke?

Yes

11. Have you ever had breast cancer or cervical cancer?

Yes

12. Have you considered other types of contraception?

Yes

13. Do you have a family history of any of the following? Please select any that apply

Blood clots

Breast cancer

Cervical cancer

Heart attack

Stroke

Please read the following leaflet:

https://www.fpa.org.uk/sites/default/files/long-acting-reversible-contraception-your-guide.pdf

14. I have read the leaflet and understand the benefits and risks of oral contraception?

Yes

15. If you would like to receive further information about alternative contraception, please select the options you are interested in below:

Barrier Methods(e.g. condoms, cap, diaphragm)

Combined pill

Contraceptive injections

Hormonal coil/IUS

Implant

Non-hormonal coil/IUD

Progesterone only pill

Your Lifestyle: Alcohol

1. How often do you have a drink containing alcohol?

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

2. How many units of alcohol do you drink on a typical day when you are drinking?

1-2

3-4

5-6

7-9

10+

3. How often have you had 6 or more units on a single occasion in the last year?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

4. How often in the last year have you found yourself unable to stop drinking once you started?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

5. How often during the last year have you failed to do what is normally expected from you because of your drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

6. How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

7. How often during the last year have you had a feeling of guilt or remorse after drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

9. Have you or somebody else been injured as a result of your drinking?

Yes, but not in the last year

Yes, during the last year

10. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Yes, but not in the last year

Yes, during the last year

Your Lifestyle- Smoking

1. Do you smoke?

Never smoked

Ex-smoker

Yes

2. Do you use an e-cigarette?

Ex-User

Yes

3. How many cigarettes did/do you smoke a day?

Less than one

1-9

10-19

20-39

40+

4. Would you like help to quit smoking?

Yes

For further information please see:

www.nhs.uk/smokefree

Further Questions

I have the following information, questions or concerns that I would like to raise with my Nurse or Doctor:

Please see the following links for further information that you may find useful:

https://www.nhs.uk/conditions/contraception/combined-contraceptive-pill/

https://patient.info/health/hormone-pills-patches-and-rings/combined-oral-contraceptive-coc-pill

https://www.nhs.uk/conditions/contraception/the-pill-progestogen-only/

https://patient.info/health/hormone-pills-patches-and-rings/progestogen-only-contraceptive-pill-pop

Follow-up

When you are happy with all your above answers, please return this questionnaire to your GP practice.

Depending upon your answers and your other medical conditions, you will be contacted if your oral contraception repeat prescription is ready for collection or if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.

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