Contraceptive Pill Review

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

Height:

Weight:

Smoking Status:

Current Smoker

Ex Smoker

Never Smoked

Are you interested in Cessation advice?

Yes

No

How many did you smoke per day?

When did you stop?

You can submit blood pressure readings in various ways

An average of readings done on a home monitor, ideally from readings taken
morning and evening for 1 week.
A reading taken on the monitor in the surgery of the waiting room
A reading taken by the health care assistant at the surgery

Latest blood pressure reading:

Systolic "Higher"

Diastolic "Lower"

Pulse

Please note that the details you give will be used to update your medical records.

*

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

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