Contraceptive Pill Review

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

  • 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.

Contraceptive Pill Review

Contraceptive Pill Review

Section

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

Contraception Pill Review

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?
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?
*