Contraceptive Pill Review

If you have been advised by the surgery to submit a contraceptive pill review, please use this form. If the information given has an impact on your contraceptive, you may need to attend a face to face appointment.

No method of contraception is 100% reliable and have to be taken properly to achieve the NHS quoted reliability rates.

If you would like to purchase a machine for family use at home, properly validated models are recommended by the British Hypertension Society and are usually available for £25-£30.

Please see our clinics and services for more information.

Please remember that our Zero Tolerance policy applies to all aspects of our surgeries, including our website.

Contraceptive Pill Review

Contraceptive Pill Review

Which surgery do you normally attend? *


In Metres
Have you been diagnosed with any new medical conditions since your last pill check?
Have you been prescribed new or started taking new over the counter medications since your last pill check?
Do you suffer from severe headaches or migraines?
Please make an appointment to see your doctor to discuss your headaches if you have not already done so.
Have you had any difficulties in understanding how to or remembering to take your contraceptive pill?
Pill taking instructions: *
How satisfied are you with your current method of contraception?
(1-10 of unsatisfied to satisfied)
Do you regularly self-examine your breasts?
We encourage all our female all our female patients to breast self-examine. If you are unsure how to do this, please read this leaflet.
Would you be interested in Long Acting Reversible methods of contraception?
Please see the leaflet for further information about alternative methods of contraception, especially about Long Acting Reversible Methods where you don’t need to remember a pill every day. In the surgery, we can offer the depot and progesterone implants.

Cervical Screening

If you have a cervix and have had any kind of sexual contact, with a man or a woman, you could get cervical cancer. Cervical screening is one of the best ways to protect yourself from cervical cancer.

Blood Pressure

We need to know your blood pressure to ensure your method of contraception is still safe.

We are soon installing BP machines which you can drop-in and use in the receptions of our 3 sites.

If you have access to a suitable machine, please specify and give a reading below. Otherwise, we will review your information above, and get back to you to arrange a blood pressure check.

Would you like to give a blood pressure reading?

Please use this date format: DD/MM/YYYY.

Terms and Conditions

If you develop new headache symptoms, a change in your vaginal bleeding pattern, or are diagnosed with any new medical conditions before your next pill check, you should let us know so that we can review the suitability of your contraceptive. It is also important to inform us if you become aware of a family history of cancer of the breast/ovary or clots in the legs/lungs that we have not discussed with you before.