Combined Oral Contraceptive (COC)/Patch Checklist

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

Last Updated: 09/03/2021

Your Details

Name *

Age *

Last Pill Check with GP: (must be ≤ 3 years) *

Date of Birth *

Phone Number *

Email Address *

Contraceptive Pill Review

Cardiovascular Risk

do you have any heart disease or blood pressure problem or take pills for blood pressure? *

Yes No

do you have a body mass index (BMI) over 35? - this is a measure of obesity *

Yes No

Have you ever had a stroke? *

Yes No

do you have diabetes? *

Yes No

*If you have more than one of the following risk factors for heart disease

*if more than one "yes" in below table, no supply.

Do you have any liver problems

If yes to any of the above risk factor, please speak with a GP

Are you aware:

LARC - (Long Acting Reversible Contraception)

An information sheet about LARC is available to download at the bottom of this page under Further Information - LARC (Long Acting Reversible Contraception)

Further Questions For A Current User:

Current contraception

compliance issues?

any side-effects?

concerns?

new or worsening headaches/migraines with pill use? *

Yes No

Any change in health (including headaches)?

are you on any over the counter medication/or new medications that might affect your pill working?

FOR NURSES USE ONLY:

DATE

WEIGHT

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Combined Oral Contraceptive (COC)/Patch Checklist

Further Information

Connect With Us