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Bangholm Medical Centre

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Request an Appointment Online
Practice Forms
Request a Sickline
Send An Image
Become A Patient
Appointments
Prescription Requests
Mental Health Resources
Annual Birthday Reviews
Our Services
Vaccination Information
Health Advice
A-Z of Community Resources

Home
Language
Home
Meet The Team
Our Services
Health Advice
A-Z of Community Resources
Appointment Reminders
Contact Us

Combined Oral Contraceptive Pill Review

Please note:

Your blood pressure is required for this form.
Forms submitted without a BP reading will not be actioned.
You can visit your local community pharmacy to have your BP checked, use an at-home BP monitor or call us for a BP check with Gill or Shelly.
If you are aged 49+, please book a face-to-face appointment.

If you are looking to start a family, we would encourage you to start taking folic acid when you stop your pill.

Last Updated: 17/04/2024

Please read before proceeding

Please note: if you do not have a blood pressure reading, this form will not be processed. Please confirm you are able to provide a blood pressure reading *

I am able to provide a blood pressure reading

Your Contact Details

First Name: *

Surname: *

Date of Birth: *

Contact Number: *

Which pharmacy would you like your prescription sent to? *

What length of prescription would you prefer? *

3 months

6 months

1 year

General Health Check

Height:

Weight:

Blood Pressure Reading: *

Do you Smoke? *

Yes

No - Never Smoked

No- Ex Smoker

Is your cervical smear up to date? *

Yes

No

Unsure

Pill-Related Questions

Which best describes your pill taking cycle? *

Every day, no pill-free days

21 days followed by 7 pill-free days

9 weeks followed by 4 pill-free days

Other (please see next question)

Name of current pill: *

Are you happy to continue on your current pill? *

Yes No

Have you experienced any side effects?

Are you aware of late/missed pill rules? *

Yes No

Are you aware that if you vomit within 2 hours of taking your pill, it may not be effective? *

Yes No

Do you struggle to remember to take your pill? *

Yes No

If you answered yes to the above, would you like an appointment to discuss other potential methods of long-acting reversible contraception? Other methods consist of: implants, coils and injections. *

Yes No

Are you concerned about any abnormal bleeding (bleeding between periods or during/after sex)? *

Yes No

Do you feel safe in your relationship? *

Yes No

Personal History

Have you ever had a blood clot? (Stroke, DVT, PE... etc.) *

Yes No

Do you suffer from heart disease? *

Yes No

Have you ever had breast cancer? *

Yes No

Do you suffer from migraines? *

Yes No

Have you ever suffered a migraine with aura? (Aura= dots, sparks or zigzags in your vision) *

Yes No

Do you have diabetes? *

Yes No

Do you take any regular over-the-counter medication?

Family History

Immediate family= Parents or siblings

Has any of your immediate family suffered from a blood clot whilst under the age of 45? *

Yes

No

Unsure

Has any of your immediate family been diagnosed with heart disease whilst under the age of 45? *

Yes

No

Unsure

Has any of your immediate family been diagnosed with genetic breast cancer? (BRCA2) *

Yes

No

Unsure

Consent

Please tick this box if you consent to us storing the data provided in this form, and consent to us contacting you if necessary. *

I consent

Feedback

Here at Bangholm, we are always looking at ways to improve our patients access and experience.

This form has been created as part of our improvement project for 2023/24.

If you have any feedback for us, please do let us know!

Thank you

How easy was this form to complete? *

Very Difficult

Difficult

Easy

Super Easy!

Would you prefer to continue using this service or would you prefer attending the surgery for your review? *

Online

Practice Appointment

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