Contraceptive Review (COC)

Name *

Date of Birth *

Weight (in kilograms) *

Height *

Blood Pressure *

Do you think you are getting any side effects from the pill? *

Yes No

If Yes, please list side effects

Are you breastfeeding? *

Yes No

Smoking status *

Never smoked

Smoker

Ex-smoker

If currently smoking, how many cigarettes do you smoke per day?

Have you ever suffered from migraines? *

Yes No

If so, was the migraine with aura (visual disturbences)?

Yes No

Are you immobile (i.e. in a wheelchair)/suffered periods of immobilisation in the past? *

Yes No

Do you have breast lumps? *

Yes No

Have you or a close relative ever had breast cancer? *

Yes (self)

Yes (relative)

No

Did you experience high blood pressure in pregnancy? *

Yes

No

N/A

Do you have/ever have had gallstones or liver issues? *

Yes No

Do you take drugs for epilepsy or tuberculosis (TB)? *

Yes No

Have you or a close relative ever had a blood clot in leg/lung? *

Yes (self)

Yes (relative)

No

Do you or a close relative suffer from any form of heart disease? *

Yes (self)

Yes (relative)

No

Have you or a close relative ever had a stroke or mini stroke (TIA)? *

Yes (self)

Yes (relative)

No

Do you take St John’s Wort? *

Yes No

Is you smear up to date? *

Yes No

Confirmation *

I confirm that that the above information is correct

Contraceptive Review (COC)

Further Information