Contraceptive Pill Review

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

You must be registered with this practice to submit this form. 

Contraceptive Pill Review

Contraceptive Pill Review

About You

Please use this date format: DD/MM/YYYY.
All women on the pill should have a “pill check/ review” at least once a year. This form will allow a healthcare professional to re-issue your prescription for the pill if safe to without you having to come in for an appointment. If you wish to see the contraception nurse for a face to face review you can book this if you prefer. If we need to speak to you before issuing more tablets we will contact you (using the mobile number on your records).

Please request your contraceptive pill in the usual way. Please click here for ways to request your pill.

Contraceptive Pill Review

Have you had any recent changes in your health that might affect your contraception? *
Have you or any family members ever been diagnosed with a blood clot in the legs or the lungs? *

Please book an appointment to see the practice nurse

Have you ever noticed a new or changing breast lump or been diagnosed with breast cancer? *

Please ask reception for our information regarding the importance of regular breast self-examination.

Have you given birth within the last 6 weeks or currently breastfeeding? *
Do you have epilepsy? *
Do you suffer from severe headaches or migraines? *

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

Are you experiencing any irregular vaginal bleeding? *

Please book an appointment to see the practice nurse

Do you currently smoke? *
Have you stopped smoking in the last year? *

My Blood Pressure

(only need for ‘combined pills’ with oestrogen and progesterone. (Not needed for progerstone only ‘mini pills’ i.e., desogestrel/cerazette/noriday)
If you do not have a blood pressure device please book in for a blood pressure reading at the Practice. Note: some pharmacies may be able to check your blood pressure for you also.
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If your blood pressure is between 140- 160 on the top number OR between 90-100 on the bottom number- please book in for a pill review within the next 2 weeks.

If your blood pressure is between 160-179 on the top number OR between 100-110 on the bottom number- please book in for a GP review to take place within a week.

If your blood pressure is 180 or more on the bottom number or 110 or more on the bottom number- please call the practice for urgent assessment.

Calculate my BMI

eg. 1.75
eg. 60.6
Please note: BMI calculator is only for patients aged 18 and over.
BMI: Underweight
Find out what this means for you at NHS Choices.
BMI: Healthy Weight
Find out what this means for you at NHS Choices.
BMI: Overweight
Find out what this means for you at NHS Choices.
BMI: Obese
Find out what this means for you at NHS Choices.
Would you like to consider longer acting forms of contraception that may not need you to remember to take your pill every day? *

Please be aware that some medication can reduce the effectiveness of ‘the pill’ (combined oral contraceptive pill) so if taking new medication, always check with the pharmacist or prescriber (this includes St John’s wort which you should avoid).

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

Should you have any questions please contact the Practice.

(no label) *
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