Contraceptive Pill Review

Height *

In Metres

Weight *

In KG

Blood Pressure (if known):

Please help us reduce the footfall through the surgery by taking your own blood pressure at home and submitting the results.

This can be done in the following ways:

Do you regularly check your breasts?

Yes

No

Please ask reception for our information regarding the importance of regular breast self-examination.

Do you suffer from severe headaches or migraines?

Yes - But the Doctor is unaware

Yes - But the Doctor is aware

No

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Are you experiencing any irregular bleeding?

Yes

No

Please book an appointment to see the practice nurse

Is your smear test up to date?

Yes

No

If your smear test is not up to date, please contact the surgery to book an appointment.

Has there been any changes to your health in the past year?

*

I confirm that the information provided is accurate to the best of my knowledge

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