Combined Contraceptive Pill/Patch Review

If you have been advised by the surgery to submit a Combined Contraceptive Pill/Patch Review please use this form.

Should you have been asked to submit a Mini-Pill/Progesterone-only Contraceptive Pill Review please visit this page.

Combined Contraceptive Pill/Patch Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Smoking Status

Do you smoke?
Please visit for information on services available to help with stopping smoking.

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 bleeding? *

Please book an appointment to see the practice nurse

Do you have problems forgetting to take your pill *
Have you ever had a stroke, a blood clot in your lungs or legs, a heart attack or any heart problems? *
If applicable, have your mother, father, brother or sister had any of the above aged under 45 years? *
Has anyone in your family had cervical cancer? *
Has anyone in your family had breast cancer? *
Do you regularly check your breasts? *

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

Have you been given information about long acting reversible contraceptives (Implants, Coils or Injections)? Please see link for more information: *

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