Contraceptive pill review

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

About You

Height (in Metres):

eg. 1.75

Weight (in Kilograms):

eg. 60.6

BMI

Blood Pressure

Please provide a blood pressure reading if you have access to a machine.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Smoking

Smoking status: Required

Smoker

Never smoked

Ex smoker

Smoker

How many cigarettes do you smoke in a day? Required

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day? Required

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking? Required

Yes

No

Ex Smoker

Rollups – How many grams of tobacco did you smoke per week? Required

Pipe – How many grams of tobacco did you smoke per week? Required

When did you give up smoking? Required

Contraception Pill Review

Do you regularly check your breasts?

Yes

No

Do you have normal periods (menstruation)? i.e. a regular cycle with no excessive or intermenstrual bleeding Required

Yes

No

Do you know how to take your medication properly? Required

Yes

No

Please specify any side effects you are having with your medication:

Have you suffered from severe headaches or migraines in the past 3 months?

Headaches

Migraines

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

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About You

Blood Pressure

Smoking

Smoker

Ex Smoker

Contraception Pill Review