CONTRACEPTIVE PILL CHECKLIST

In order to provide the contraceptive pill safely we need to ask you a number of questions. We would be grateful if you could complete this form when you submit your next repeat prescription request.

If you are having any problems with your medication, or would like to consider alternative contraception options, please speak to one of our Practice nurses, who will be able to advise you, or refer you to the Doctor as appropriate.

Personal Details

(That you are happy for us to contact you on, if there are any queries)

Blood Pressure Questionnaire

Please measure your blood pressure using the BP machine at the surgery / chemist / home and record the reading here:

Are you a smoker?

Are you a smoker?

Would you like help giving up?

Would you like help giving up?


Are you aware:

a) How the pill works?

a) How the pill works?

b) What to do if you miss a pill?

b) What to do if you miss a pill?

c) That the contraception may not work if you have diarrhoea or vomiting?

c) That the contraception may not work if you have diarrhoea or vomiting?

d) That the contraceptive pill does NOT protect you from Sexually Transmitted Infection (STI), so you will need to use a condom as well to protect yourself?

d) That the contraceptive pill does NOT protect you from Sexually Transmitted Infection (STI), so you will need to use a condom as well to protect yourself?

Do you suffer from migraines?

Do you suffer from migraines?

If so, do you suffer from visual symptoms or changes in sensation or muscle power on one side of your body?

If so, do you suffer from visual symptoms or changes in sensation or muscle power on one side of your body?

Do you have parents or siblings who have had heart disease or stroke under the age of 45?

Do you have parents or siblings who have had heart disease or stroke under the age of 45?

Do you have diabetes?

Do you have diabetes?

Have you or any family member under the age of 45 had a deep vein thrombosis or Pulmonary Embolus (blood clot in the leg or lung) ?

Have you or any family member under the age of 45 had a deep vein thrombosis or Pulmonary Embolus (blood clot in the leg or lung) ?

Do you have blood clotting illnesses / abnormalities?

Do you have blood clotting illnesses / abnormalities?

Do you have any family history of breast cancer under the age of 50?

Do you have any family history of breast cancer under the age of 50?

Are you aware of the alternatives such as long acting reversible contraceptives?

Are you aware of the alternatives such as long acting reversible contraceptives?

Would you like to book a consultation with a doctor to discuss or arrange fitting a long acting reversible contraceptive?

Would you like to book a consultation with a doctor to discuss or arrange fitting a long acting reversible contraceptive?

Please measure your blood pressure reading: 

If you do not have access to a blood pressure machine, please use the surgery machine located in the foyer of the health centre. If we do not receive a blood pressure reading we will be unable to process your prescription request.


Please remember cervical smear testing
(EVERY 3 years for women aged 25-50 and EVERY 5 years for women aged 50- 65)

Thank you for completing this form.
If we have any problems with re-issuing your prescriptionwe will contact you. If not, your prescription will be ready for you to collect within 3 working days.

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