Contraception Questionnaire

In order to provide a prescription for the contraceptive pill safely we need to ask you a number of questions. The process of reviewing this information and re-issuing a prescription may take up to 5 working days.  You can be provided with a prescription for one month supply of your pill if needed whilst we deal with your request, please indicate on the questionnaire if this is needed.

Contraceptive Questionnaire
Please use format day/month/year e.g. 12/05/1979
Enter Email
Confirm Email

Height and Weight

Weight

Please provide details of your heigh and weight in either Metric or Imperial units.
Unit of measurement *
Choose your preferred unit of measurement.
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

Smoking Status

Do you smoke?
How many cigarettes do you smoke a day?
Would you like help to quit smoking?
Do use an e-Cigarette
Are you up to date with your cervical smear ?
Are you aware of the missed pill/late pill rules ?
Are you aware that the contraceptive pill most likely will not be effective if you vomit within 2 hours of taking the pill ?
Do you suffer from migraines or have you developed migraines since your last contraception review ?
Do you take any regular over the counter medicines ie: St Johns Wart ?
Is there any change to your family medical history regarding Stroke ?
Is there any change to your family medical history regarding Heart Disease ?
Is there any change to your family medical history regarding Deep Vein Thrombosis (DVT or clot) ?
Is there any change to your family medical history ?
Would you like to discuss this further ?
Are you aware of the self-administering contraceptive injection ?
Would you like to discuss this further ?
Which best describes your pill taking cycle ?
Are you concerned about any abnormal bleeding such as bleeding between periods or during/after intercourse ?
Do you feel safe in your relationship ?
Do you require a prescription for one month supply of your contraceptive pill ?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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