Contraceptive Pill Review

If you have been advised by the surgery to submit a contraceptive pill review please use this form.

Please take a look at the links below for advice on what to do if you miss a combined pill/or have diarrhoea and vomiting/or general advice:

If you have any concerns about sexually transmitted infections (STIs), please speak to one of our doctors or there is also a free website that you can use:

Contraceptive Pill Review

Contraceptive Pill Review

About You

Blood Pressure

Was this reading done at home or a chemist?

If you are unable to provide this you can book an appointment with our nurse.


In Metres eg. 1.75
In KG eg. 60.6
Please note: BMI calculator is only for patients aged 18 and over.

Please book an appointment with one of our nurses for these measurements if you are unable to obtain them at home or your local chemist.

Contraception Pill Review

Have you ever suffered from severe headaches or migraines with aura? *

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Have you had any irregular bleeding on your pill (this may be bleeding between periods or after sex)? *

Please book an appointment to see the practice nurse

Have you missed any pills? *
Have you or any family member been diagnosed with a blood clot in the leg or the lung (these are called a DVT or PE)? *
Have you noticed a new or changing breast lump or ever been diagnosed with breast cancer? *
Are you a smoker? *
Are your smears up to date? *


Would you like to consider a longer acting form of contraception which would avoid you needing to remember to take a pill every day? *