UMC Pill Check Questionnaire

 
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All questions marked with a * are mandatory

Personal Details
Please double check you've entered the correct email address
May be used to identify you
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Questions
What type of pill request would you like?: *
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?: *
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Blood Pressure

If you do not have a machine at home, please come to reception and have your blood pressure and weight measured on the practice machine.

Book an appointment to see a GP

As your Blood Pressure is over 140/90 this needs to be reviewed

You cannot continue with this form: *
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Lifestyle

What is your Height?

What unit of measurement are you using?: *

What is your Weight?

What unit of measurement are you using?: *
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Further Questions
Are you having any side effects or problems from your contraceptive pill that you would like to discuss with your GP/nurse?: *
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Providing NHS Services

University Medical Centre
Giles Lane
Canterbury
Kent
CT2 7PB

Telephone: 01227 469333

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