Oral Contraception Questionnaire

Patients who are 16 years old and over and taking a contraceptive pill provided by ourselves may no longer be required to attend for a pill check appointment. We now use a questionnaire for patients to order their contraceptive pill repeat prescription. We require an up to date height, weight and blood pressure (BP) in order to issue the prescription. These can be measured at home. Lots of people now have their own BP machine, have a family member who they can borrow one from or have the ability to check their BP at work. However if you have no access to a machine to check your BP then please contact the surgery and we will arrange to have your BP checked at the surgery. In order to provide the contraceptive pill we need to ask you a number of questions. We would be grateful if you could complete this form when you submit your next pill request. If you are having problems with your pill or would like to consider alternative contraception then please make it clear on the form and a follow-up appointment will be made for you.

Last Updated: 27/10/2021

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I confirm that I have read and understood the information provided to me regarding contractive medication and the options in relation to long action reversible contraception