Oral Contraception Review

Please complete the following questions to allow your health care professional to assess your current contraception. This questionnaire is for a routine review of your use of contraception.

If you are experiencing any of the following ring your GP immediately:

  • Unusual or severe headaches
  • A faint or collapse
  • Migraines that are worse than normal
  • Painful swelling of your leg
  • Weakness or numbness of an arm or leg
  • Sudden problems with your speech or sight
  • Difficulty breathing
  • Coughing up blood
  • A bad pain in your tummy (abdomen)
  • Pains in your chest, especially if it hurts to breathe in
Oral Contraception Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Your Contraception

Have you been experiencing side effects since you started taking the pill?
Do you currently experience or have a history of Migraines?
Have you ever had any blood clots?
eg. Deep Vein Thrombosis or Pulmonary Embolism
Have you ever had a heart attack or stroke?
Have you ever had breast cancer or cervical cancer?
Have you considered other types of contraception?
Do you have a family history of any of the following?
Please select any that apply
If you would like to receive further information about alternative contraception, please select the options you are interested in below:

Your Lifestyle - Alcohol

This is one unit of alcohol:

And each one of these, is more than one unit:

How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *