UMC Pill Check Questionnaire

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Personal Details

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May be used to identify you

Questions

Pill Request: *

tick one

Yes/No please include pill name or state same as last time

Yes/No include name of medication or supplement

Yes/No include details

4. Are you getting new or worsening headaches?: *

5. Do you get migraines?: *

A migraine is usually a moderate or severe headache felt as a throbbing pain on one side of the head

6. Do you have an aura with your migraines?: *

An aura is where you have warning signs before your headache begins such as changes to your vision – black spots / wavy lines or numbness/pins and needles

7. Have you ever had a blood clot (also known as DVT/PEs)? These are clots that cause swollen and painful arms, legs or chest pain.: *

8. Have any of your immediate family ever had a blood clot (DVT/PE)? (Your immediate family includes your father, mother, brother and sister): *

Yes/No/I don't know (please state relative and approximately what age they were diagnosed)

10. Do you have any new unexpected bleeding between your periods since your last review?: *

11. Do you have any new bleeding after sex since your last review?: *

12. Are you up-to-date with your cervical screening (smear test)?: *

13. Are you interested in having any sexual health screening?: *

This is important as the oral contraceptive does not protect against sexually transmitted infections

14. What is your smoking status?: *

in KGs

in cm

Are you having any side effects or problems from your contraceptive pill that you would like to discuss with your GP/nurse?: *

Please include a postcode or address/location

Privacy Consent

This form collects personal and medical informanot tion 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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UMC Pill Check Questionnaire

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