Contraceptive Injection Review

 
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contraception

Contraceptive Injection Review 

This form includes patients taking either Depo-provera or Sayana Press injectable contraception.

Please only submit this form if you have been requested to do so by the practice.

If you have a clinical query please call us on 0131 370 3999.

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All questions marked with a * are mandatory

Personal Details
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Contraceptive Injection Review
Have you had any recent changes in your health that might affect your contraception?: *
Have you ever had a blood clot in your legs or lungs (deep vein thrombosis or pulmonary embolus)? : *
Do you have any blood clotting abnormalities?: *
Do you have parents or siblings who have ever been diagnosed with a blood clot in their legs or the lungs (deep vein thrombosis or pulmonary embolus)?: *
Do you have parents or siblings who have had heart disease or strokes under the age of 55? : *
Do you have parents or siblings who have had breast cancer under the age of 50?: *
Have you given birth within the last 6 weeks?: *
Do you suffer from severe headaches or migraines? : *
Are you experiencing any irregular vaginal bleeding? : *

Book an appointment to see a GP

You cannot continue with this form: *
Do you currently smoke or have you stopped smoking in the last year?: *
Are your smears up to date?: *
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Blood Pressure

If you do not have a machine at home, please come to reception and have your blood pressure and weight measured on the practice machine.

Higher number
Lower number

Book an appointment to see a GP

As your Blood Pressure is over 140/90 this needs to be reviewed

You cannot continue with this form: *
Body Mass Index
Blood Pressure

How to calculate your Body Mass Index (BMI)

 
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Dalhousie Medical Practice
Bonnyrigg Health Centre
109-111 High Street
Bonnyrigg
EH19 2ET

Telephone: 0131 370 3999

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