Contraceptive Pill Review

Please complete the following questions to allow your health care professional to assess your current contraception.

This questionnaire is for a routine review of your use of contraception. If you are experiencing any of the following, please ring your GP immediately:

  • A bad headache, or migraines.
  • Painful swelling of your leg.
  • Weakness or numbness of an arm or leg.
  • Sudden problems with your speech or sight.
  • Difficulty breathing.
  • Coughing up blood.
  • Pains in your chest, especially if it hurts to breathe in.
  • A bad pain in your tummy (abdomen).
  • A faint or collapse.
Contraceptive Pill Review

About You

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

Your Current Health Details

In M
in mmHg
in mmHg
in BPM
Have you been experiencing side effects since you started taking the pill? *

Your Medical History

Do you currently experience, or have a history of Migraines?
Have you ever had any blood clots?
(e.g. Deep Vein Thrombosis or Pulmonary Embolism)
Have you ever had a heart attack or stroke?
Have you ever had breast or cervical cancer?
Do you have a family history of any of the following?
Please select all that apply

Alternative Contraception

Would you like any further information about Long Acting Reversible Contraception? *
(e.g. contraceptive implant or coil)
If you would like to receive further information about alternative contraception, please select the options you are interested in:

Alcohol and Smoking Questions

How many units of alcohol do you drink on a typical day drinking?
How often have you had 6 or more units on a single occasion in the last year?
Do you smoke?
Do you use an e-cigarette (vape)?
If you smoke, would you like help to quit smoking?
For further information, please see

Further Information

After completing all of the above questionnaire, please click submit below. Your GP practice will then inform you if your oral contraception repeat prescription is ready for collection or if a further assessment is required.