Contraceptive Pill Review
Who are you completing this form for?
For example, on behalf of a child or dependent
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you

About You

eg. 1.75
eg. 60.6

Blood Pressure

Please provide a blood pressure reading if you have access to a machine.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Please use date format: DD/MM/YYYY

Smoking

Smoking status:

Contraception Pill Review

Do you regularly check your breasts?
Do you have normal periods (menstruation)? i.e. a regular cycle with no excessive or intermenstrual bleeding
Do you know to take your your medication properly?
Have you suffered from severe headaches or migraines in the past 3 months?