Contraceptive Pill Review

If you have been advised by the surgery to submit a contraceptive pill review please use this form.

Heathcote Contraceptive Pill Review

About You

In Metres
In KG
Are you a smoker? *
Would you like help giving up?

Blood Pressure

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Contraception Pill Review

Are you aware of what to do if you miss a pill? *
Are you aware that the contraceptive pill may not work if you have diarrhoea, have been vomiting or are on antibiotics? *
Are you aware 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 severe headaches or migraines? *
Do you experience visual symptoms or changes in sensation or muscle power on one side of you body? *
Do you have parents or siblings who have had heart disease or stokes under the age of 45? *
Do you have diabetes? *
Have you had a deep vein thrombosis or pulmonary embolus? *
Do you have parents or siblings that have had a deep vein thrombosis or pulmonary embolus under the age 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 (LARC)? *
For information regarding LARC, please read our Long Acting Reversible Contraception (LARC) information.
Would you like to book a consultation with a doctor to discuss or arrange fitting of a long acting reversible contraceptive? *
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