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Fairbrook Medical Centre > Forms > Health Review Forms > The Combined Pill Review Form

The Combined Pill Review Form

The Combined Pill — e.g. Microgynon, Rigevidon, Ovranette, Yasmin

 Below there are links to information

You will need an up to date blood pressure reading before you complete the online details. This can be easily organised using a home monitoring machine or through local pharmacies and Gyms. Please record this before you complete the application.

Different Contraceptive Choices

Combined pill including new ways to take it

Your contraceptive guide

Combined Pill
Enter Email
Please use format day/month/year e.g. 12/05/1979

Your Height and Weight

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

Combined Pill Review

e.g. 120/70
Do you smoke? *

Are you aware…

How the pill works?
What to do if you miss a pill?
That the contraceptive pill may not work if you have diarrhoea, have been vomiting or are on antibiotics
That the contraceptive pill DOES NOT protect you from sexually transmitted infections, so you will need to use a condom as well to protect yourself
Do you suffer from migraines? *
Do you have diabetes?
Have you had a deep vein thrombosis or pulmonary embolus?
Do you have any parents/siblings that have had heart disease, strokes, deep vein thrombosis or pulmonary embolus under the ages of 45?
Do you have any blood clotting illnesses/abnormalities?
Do you have any family history of breast cancer under the age of 50?
Are you aware of the alternatives such as long acting reversible contraception ?
Would you like to book a consultation to discuss/arrange fitting of a long acting reversible contraceptive? *
One of our clinicians may contact you on this number.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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