Contraception Review

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

Please be aware that once this form has been submitted, it will be held within your health record.

  • Are you under 16?
  • Do you wish to change your pill?
  • Are you having problems with your pill?
  • Is this the first time you’ll be taking ‘the pill’?
  • Are you a new patient at Wymondham Medical Centre (ie. never had the pill prescribed here before)?

 

If you answer yes to any of the questions above, please do not use this form and instead use the Request an appointment with a Nurse or Healthcare Assistant form.

Contraception Review

Contraception Review

Section

Is this for a new prescription of a pill or are you already established on one? *

Contraception Review

Please answer N/A to any fields that are not applicable.

Please specify: *
Smoking: *
Do you use an electronic cigarette? *
Please specify: *

Blood Pressure Reading

/
In Metres
In KG
Do you bleed between periods? *
Do you bleed after sex? *
Do you have amenorrhoea? (no periods) *
Do you have any history of migraines? *
Do you get an aura? *
Have you had a screening test for sexually transmitted infections within your current relationship? *
Do you take any other medications? *
Are you planning to travel abroad currently? *
Will you be staying at a high altitude? *
Do you have any concerns regarding domestic abuse/violence? *
*