Contraceptive Method Review



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Personal Details

This form is for the repeat prescription of the contraceptive methods which include the contraceptive pill, patch or vaginal ring, and should be completed if you are a current user of these methods and have already been prescribed this method in the last 12 months.

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May be used to identify you
Medical History

If you do not have an up to date blood pressure, please use the machine in the waiting room at the surgery.

Please be aware that certain over the counter medicines and herbal remedies such as St.John’s wort can reduce the efficiency of the pill. Please check with a health care professional if you have any concerns.

A migraine is usually a severe headache felt as throbbing pain at the front or on one side of the head. Some people experience a sensation, or aura, just before their migraine starts. Symptoms of aura include flashes of light or blind spots, difficulty focusing and seeing things as if you are looking through a broken mirror. This is known as migraine with aura.

If so, we recommend you request an online sexual health screen at SH:24.

If you experience:

  • A sudden sharp pain in your chest, breathlessness or coughing up blood
  • Painful swelling in your legs
  • Weakness, numbness or bad “pins and needles” in an arm or leg
  • Unusual headaches or migraines that are worse than usual
  • Sudden problems with your speech or eyesight

Seek medical advice immediately.

Contraception Review

If you have new concerns/questions please book an appointment to discuss further.

Information about what to do if you miss a pill can be found on the Sexwise Website.

Patient Questions

If you develop any new conditions, tell your clinician so that they can check its safe for you to continue with your contraceptive method.

If you go into hospital for an operation or have an accident which affects the movement of your legs or mobility, tell the doctor you are taking the combined hormonal contraception. You may need to stop taking the pill or need other treatment to reduce the risk of developing thrombosis (blood clots). There are other contraceptive methods you can use instead.

Be breast aware, visit How should I check my breasts | NHS for further advice.

If you would like to read more about this and other contraceptive options please visit Which method of contraception is right for me? | Sexwise and go to our contraception page on the website.

If at any time you have concerns about your medication then please an appointment with a health care professional, this can be the clinical pharmacist, nurse or GP.

Please note the details you give will be used to update your medical records. If your correct contact information is not entered we will not be able to respond to you.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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