Form: Contraceptive Pill Repeat Prescription Request

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Personal Details

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May be used to identify you

Your Health

Blood Pressure

You can check your blood pressure at a local pharmacy or use the machine in reception

Your systolic blood pressure is the top number on your reading

Your diastolic blood pressure is the bottom number on your reading

Weight & Height

There are scales available in the waiting area of the surgery

Please use kgs

Please use Metric Measurements

Smoking

Please confirm your smoking status: *

If you can't remember the exact day please enter 01 for the day

If the above results are judged to be unsafe for continuation of the medication, you will be asked to see a practice nurse.

Was the contraceptive pill first issued within the last 3 months?: *

Do you have any problems with your general health?: *

Do you have any problems or side effects using your contraceptive pill?: *

Do you understand the ‘missed pill rules’ for your particular type of contraceptive?: *

Do you have any health matters you wish to discuss with the GP in relation to the pill?: *

Do you believe there is a chance you could be pregnant? : *

Have you ever suffered migraines / severe headaches / frequency headaches?: *

Have you had any changes in the pattern/presentation or frequency of your headaches following the use of the pill?: *

Have you ever suffered from visual or auditory disturbance prior to getting a headache?: *

Have you suffered vaginal bleeding between periods that have not been resolved or during the last course of 3 months contraceptive use?: *

Have you suffered vaginal bleeding during or after sexual intercourse recently?: *

Have you suffered unusual discharge since last prescribed?: *

Have you had a history of blood clots or blood clotting disease?: *

Have you ever suffered from cancer?: *

Declaration

I understand that the contraceptive pill has certain risks associated with its use, as outlined in the patient leaflet previously provided with my pills, and that smoking increases these risks. The information provided is correct to the best of my knowledge.

A leaflet will be provided with you prescription that discusses long acting contraceptive options, please contact the medical centre and ask for an appointment if you wish to discuss this further.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Form: Contraceptive Pill Repeat Prescription Request

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