Contraceptive Pill Review

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

Every twelve months you are required to have a blood pressure check. You do this yourself and let us have the reading or book an appointment to see the practice nurse.

Contraceptive Pill Review

Contraceptive Pill Review

If you are human, leave this field blank.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Contraception Review

Do you have a history of headache with flashing lights?

Yes

No

Are you a smoker?

Yes

No

How many do you smoke per day?

Blood pressure reading:

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Weight:

Height:

Has anyone discussed long acting contraception with you?

Yes

No

For more information, please visit www.fpa.org.uk