Westcliffe Pharmacy Contraceptive Review

Name

First

Last

Date of Birth:

Address:

Please include post code

GP Practice:

Phone Number:

Email

Are you requiring a repeat supply of a contraceptive pill or are you wishing to start taking a contraceptive pill for the first time?

Repeat supply of current pill
New start of contraceptive pill

What is the name of your current contraceptive pill?

Have you previously been prescribed your contraceptive pill by your GP practice?

Yes
No

Do you wish to change your current contraceptive pill?

Yes
No

Have you missed any pills or had a break in taking them since your last supply?

Yes
No

Have you had any side effects from your contraceptive pill?

Yes
No

Are you taking any other prescribed medication?

Yes
No

Do you take any other medication (other than prescribed by your GP)?

Yes
No

Have you had your blood pressure checked in the last 3 months?

Yes
No

If Yes, Please enter the blood pressure reading below:

If you do not have a blood pressure monitor at home, you can get your BP checked at your nearest local pharmacy.

Are you pregnant, or is it possible you could be pregnant?

Yes
No

Do you have long periods of immobility?

Yes
No

Do you smoke cigarettes?

Yes
No
Ex-Smoker

What is your Height and Weight?

Do you have diabetes?

Yes
No

Have you ever had a deep vein thrombosis (DVT) or pulmonary embolus (PE)?

Yes
No

Do you have a current of past history of heart disease?

Yes
No

Do you have a direct relative (parent, sibling, child) who have a had heart disease, a stroke, DVT, or PE under the age of 45?

Yes
No

Do you have any blood clotting illnesses or abnormalities?

Yes
No

Do you have any problems with your heart?

Yes
No

Have you ever been diagnosed with atrial fibrilation?

Yes
No

Do you suffer from migraines?

Yes
No

If yes, do you experience visual symptoms, or changes in sensation on one side of your body?

Yes
No

If yes, did your first migraine attack occur when you were taking your contraceptive pill?

Yes
No

Do you have a past or current history of breast cancer?

Yes
No

Do you have any undiagnosed breast symptoms?

Yes
No

Do you have any family history of breast cancer under the age of 50?

Yes
No

Do you have any past or current history of any other cancer?

Yes
No

Do you have any form of liver disease or liver impairment?

Yes
No

Do you have gall bladder disease that causes you symptoms or is medically managed?

Yes
No

Do you suffer with acute/active inflammatory bowel disease or Crohn's disease?

Yes
No

Have you had any bariatric surgery or other surgery which has reduced your ability to absorb things from your stomach?

Yes
No

Do you suffer from cholestasis, a condition caused by blocked or reduced flow of bile fluid?

Yes
No

Do you have any planned major surgeries?

Yes
No

Have you ever been diagnosed with Anti-phospholipid syndrome with or without lupus?

Yes
No

Have you ever had an organ transplant that has resulted in complications?

Yes
No

requiring you

Do you have severe kidney impairment or acute renal failure?

Yes
No

Have you been diagnosed with acute porphyria?

Yes
No

Once you have filled out the entire form, a pharmacist will review and will be in touch via phone or email within 48hours