Patient Address, Telephone Number and Email:
what method of contraception have you used in the past and have you had any problems with this? (If not please skip to question 9)
What are your reasons for stopping/changing? (This will help to guide us in helping you choose the best contraception to suit your lifestyle)
Are you aware that the contraceptive pill does not protect you from sexually transmitted infections (STIS) SO YOU WILL NEED TO USE A CONDOM AS WELL TO PROTECT YOURSELF?
Age of child if breast feeding:
Do you suffer from migraines?
Do you suffer from high blood pressure?
Have you had a deep vein thrombosis (dvt) or pulmonary embolus (pe)?
Do you have parents or siblings who have had a deep vein thrombosis (dvt) or pulmonary embolism (pe) under the age of 45?
Do you have any blood clotting illnesses or abnormalities?
Are you currently suffering from or have previously experienced breast cancer?
Are you a breast cancer BRCA1/BRCA2 gene carrier?
Have you had a change in bleeding pattern or new bleeding pattern?
If you are a smoker, do you want help to stop smoking? Here is some advice on ways to quit smoking, local services and general tips: https://www.nhs.uk/better-health/quit-smoking/
Have you been diagnosed with any new health conditions since we last issued you a prescription?
If yes to the above question, please state:
Are you taking any medication or supplements not prescribed by the surgery? Such as St John's wort or medications for hiv or epilepsy not prescribed by the surgery. (Please be aware to avoid taking any supplements within 2 hours of taking your pill)
If yes to the above question, please state:
Would you like to consider one of the long acting reversible contraceptive methods such as the contraceptive injection, implant or coils? These increase the convenience of your contraception as they remove the need to remember something every day. Please copy the following link to see further information relating to LARCS: https://patient.info/sexual-health/long-acting-reversible-contraceptives-larc
It is important that you are aware of: how the pill works, what to do if you miss a pill, that the contraceptive pill may not work if you have diarrhoea or vomiting and the risks of contraceptive pills. If you are not aware or if you require further information please copy this link or you can discuss further with a clinician: https://www.nhs.uk/conditions/contraception/