Contraception Review Form

DD slash MM slash YYYY
Name
Address
DD slash MM slash YYYY

Personal Medical History

History of Migraines
DVT (Blood clot in leg)
PE (Blood clot in lung)
Breast Cancer
Irregular Bleeding between Periods
High blood pressure
Epilepsy
Heart Disease
Stroke
Bleeding after sex

Family History

Blood clotting problems e.g. Factor V Leiden
DVT (Blood clot in leg)
PE (Blood clot in lung)
Breast Cancer
High Blood Pressure
Epilepsy
Heart Disease
Stroke

Lifestyle

Do you smoke?
If yes, please visit: www.nhs.uk/smokefree for help to stop smoking.
If you do smoke, please confirm:
If yes, please visit: www.nhs.uk/smokefree for help to stop smoking.
Please confirm whether you are up to date with your cervical screening:
Aged 25 to 49, a test is required every 3 years. Aged 50 to 65, a test is required every 5 years. If you think you are due/overdue please book in with a practice nurse.

Examination

If you do not have access to a Blood Pressure monitor at home, please visit the practice to use the Keito Machine located in the waiting room.
Do you remember to take your pill regularly?
Are you familiar with the missed pill rules & what to do if you forget your pill?
Have you already run out of your pill? (We recommend you attend your pill check every 12 months, and give 48hrs for medication requests)
If you have not taken your pill for more than 2 days [12 hrs if progesterone only pill eg zeletta, cerazette] (or are more than 2 days late re-starting it after your pill free week then you will need to use additional precautions for 7 days. If you have had unprotected sex during this time you will need emergency contraception – see nurse or pharmacist ASAP.
Are you happy for your prescription to be sent to your local pharmacy?

Are you aware of longer acting methods of contraception i.e. implant, depo injection, coil? If you would like any further information about these methods, please book an appointment with Nurse Debbie or a telephone appointment.

Are you aware that you can get emergency contraception from the pharmacy or practice nurse if you miss pills?

Additional Information

Practice Newsletters

Carers

Domestic Violence and Abuse

GDPR, FoI and Policies

Live Well Cheshire West

National GP Patient Survey

Non-NHS Services

Patient Participation Group (PPG)

SilverCloud Self-Referral

Social Prescribing

Young People

Health Questionnaires

Vacancies