Contraceptive Pill Review

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

Contraceptive Pill Review

Contraceptive Pill Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
kg or stone & pounds
cm or feet & inches
Do you have diabetes? *
Are you allergic to Oestrogen or Progesterone? *
Are you taking prescription medications or the herbal medicine St Johns Wort?
Has anyone in your close family had a blood clot, stroke or heart attack under the age of 50? *
Have you ever had blood clots, a stroke or mini stroke, heart disease (including heart attack) irregular heartbeat, high cholesterol problems or problems with your heart valves? *
Do you have limited mobility (e.g. are you a wheelchair user)? *
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