Contraceptive Pill Review Personal DetailsName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Email Phone(Required)Name of Current Contraceptive Pill(Required) Contraception ReviewAre you satisfied with your current contraception?(Required) Yes No Are you looking at stopping or changing your contraceptive method in the next 12 months?(Required) Yes No Are you aware of the alternatives such as long acting reversible contraception (i.e. coil, or implant)?(Required) Yes No Would you like to discuss an alternative long term contraceptive?(Required) Yes No Do you have any current problems with your pill?Health QuestionnaireCurrent Height(Required)Current Weight(Required)BP Reading (If you have access to a home blood pressure monitor) Current Smoking Status(Required) If so, how many do you smoke a day? Average Weekly Alcohol Intake (Units)(Required)Do you have a q-risk >10 or a past history of heart disease, stroke, TIA or arterial disease?(Required) Yes No Don't Know Have you or any family member, had a deep vein thrombosis or pulmonary embolus (blood clot in the leg or lung), under the age of 45?(Required) Yes No Don't Know Do you suffer from migraines?(Required) Yes No Do you have a current history or past history of breast cancer?(Required) Yes No Do you have a family history of breast cancer?(Required) Yes No Don't Know If you answered yes to the above, please state the relationship, and whether the family member is on the maternal or paternal side of your family: Do you check your breasts regularly?(Required) Yes No Do you attend for cervical screening?(Required) Yes No Have you got a private prescription for the weight loss injection (i.e. Ozempic, or Mounjaro)?(Required) Yes No Do you take any medications regularly that we do not prescribe, for example, herbal medicines?(Required) Yes No
