Contraceptive Pill Review

 
Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)

Please Note

You will require an up to date blood pressure reading in order to complete this form

GPPAQ

Contraceptive Pill Review 

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.

Processing

All questions marked with a * are mandatory

Personal Details
Please double check you've entered the correct email address
May be used to identify you
Processing
Contraception Pill Review
What type of pills are you taking/required: *
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? : *
Do you experience visual symptoms or aura with your migraine?: *
Are you experiencing any irregular vaginal bleeding? : *

Book an appointment to see a GP

You cannot continue with this form: *
Do you currently smoke? (vaping/ecigarettes do not count): *
Have you smoked in the last year? (vaping/ecigarettes do not count): *
Are your smears up to date?: *
Processing
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

Your BMI is 

Processing
Contraceptive Pill

Effectiveness of the pill

  General advice on the pill including different ways to take it

  What to do if you miss a pill

 

Some medication can reduce the effectiveness of ‘the pill’

  • Always check with the pharmacist or prescriber if you are taking any new medication or suppliments 
  • this includes St John’s wort which you should avoid
Are you taking Mounjaro or any other weight loss medication?: *
Processing
Stop Smoking

Longer acting forms of contraception

Long-acting reversible contraception is contraception that doesn't depend on you remembering to take or use it to be effective.

  More information

Would you like to consider longer acting forms of contraception that may not need you to remember to take your pill every day?: *

How to get a longer acting form of contraception

If you would like a contraceptive implant, intra uterine device or contraceptive injection, please arrange to speak with a GP

Processing

Privacy Consent

Processing

There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.

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

Telephone: 0131 370 3999

healthier scotland logo

© Tree View Designs

Facebook