Contraceptive Pill Review

Height *

In Metres

Weight *

In KG

Do you regularly check your breasts?

Yes

No

Please ask reception for our information regarding the importance of regular breast self-examination.

Do you suffer from severe headaches or migraines?

Yes - But the Doctor is unaware

Yes - But the Doctor is aware

No

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Are you experiencing any irregular bleeding?

Yes

No

Please book an appointment to see the practice nurse

*

I confirm that the information provided is accurate to the best of my knowledge

Terms and Conditions: *

I confirm that this problem is not an emergency. I understand that the practice will not deal with this problem while the practice is closed.

If the problem worsens and may require immediate help, I will visit NHS 111 Online or call 111. In an emergency, I will call 999.

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