Contraceptive Pill Review Contraceptive Pill Review Full Name:*Date of Birth:*Please use the format dd/mm/yyyyBest contact number should we need to contact you:*BLOOD PRESSURE & WEIGHTIf you do not have access to a blood pressure monitor or weighing scales, please call into the surgery and use our healthpod in reception.Systolic (higher) reading:Diastolic (lower) reading:Weight:YOUR HEALTHPlease answer ALL questions in this sectionWill you be 35 years or older within the next 12 months?*YesNoDo you smoke?*YesNoHave you, or any of your immediate family (mum, dad, siblings) been diagnosed with any of the following conditions within the past 12 months?* Deep vein thrombosis (a blood clot in the veins of the leg) Pulmonary embolism (a blood clot in the lungs) Stroke or cerebro-vascular disease Heart disease None of the above Have you been diagnosed with or experienced any of the following conditions in the past 12 months?* Unexplained leg swelling Chest pain that is worse when breathing deeply or unexplained shortness of breath High blood pressure High Cholesterol Diabetes Liver disease Gallbladder disease including gallstones Epilepsy Raynauld's disease Breast cancer None of the above Are you currently taking any of the following medications?* Anti-epileptic mediction Rifampacin St Johns Wort None of the above Do you suffer from migraines with aura, or visual loss/disturbance, or headache associated with weakness or numbness on one side of your face or body, or difficulty with speech?*YesNoA migraine is usually a severe headache felt as throbbing pain at the front or on one side of the head. Some people experience a sensation, or aura, just before their migraine starts. Symptoms of aura include flashes of light or blind spots, difficulty focusing and seeing things as if you are looking through a broken mirror. This is known as migraine with aura.Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months?*YesNoHave you forgotten to take your pill on more than one occasion per month?*YesNoWould you like to discuss 'what to do in the event of a missed pill' with a practice nurse or GP?*YesNoWould you like to discuss long acting reversible contraception options with a practice nurse or GP?*YesNoDo you have any questions regarding your contraception or this questionnaire?*YesNoPATIENT DECLARATIONI confirm that all of the information that I have provided on this form is correct at the time of completing the form. I confirm that I will inform my GP should there be any changes to my health whilst I am taking oral contraceptive tablets.* Please tick to confirm the above before submitting your answers Please note the details you give will be used to update your medical records. If your correct contact information is not entered we will not be able to respond to you.