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
Oral Contraception review
Please enter Date of Birth as DD/MM/YYYY
Your Contraception
Your Lifestyle: Alcohol
Your Lifestyle- Smoking

For further information please see:


Further Questions


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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