Online Oral Contraceptive Pill Check

1
Please complete the questions below. You will need to enter your blood pressure, height and weight. You will need an up to date blood pressure reading to order a pill containing oestrogen. Many people have their own machines to measure blood pressure. You may wish to consider buying your own machine. We would recommend an arm machine (not wrist) as it is more accurate. We currently use Omron brand but most machines work very well. This may be a small cost now for something you use over many years. If you are unable to measure your blood pressure at home, please ask at reception to borrow our machine to use on the premises. (It is free to use the machine in the surgery but you will need to leave a £20 refundable deposit in cash if you wish to take the machine off the premises)
2
Name* This field is required.
First Name
Last Name
3
Date of Birth* This field is required.
4
Email
example@example.com
5
Phone Number* This field is required.
Area Code
Phone Number
6
Weight in kilograms
7
Height in metres
8
Systolic blood pressure (higher number)If you are requesting a pill containing oestrogen, a recent blood pressure reading is needed.
9
Diastolic blood pressure (lower number)If you are requesting a pill containing oestrogen, a recent blood pressure reading is needed.
10
What is the name of your oral contraceptive pill?
11
How long have you been taking this pill for?
12
Please read the information in the following link

https://www.nhs.uk/conditions/contraception/
13
Are you happy with your current pill and want to continuing taking it?
Yes, I have read the information on other methods of contraception, including long-acting methods such as the implant, coil and injection, but I want to stay on the same pill as I had last time
No
14
If you are not happy with your current method of contraception and want to discuss other options, please contact reception to book an appointment with a doctor. If you know the name of an alternative oral contraceptive pill that you want to consider, please enter the name below.
15
Suggested alternative
16
Have you ever had a DVT or PE (blood clot in the leg or lungs)?* This field is required.
Yes
No
17
Please describe
18
Do you have a family history of DVT or PE (blood clot in the leg or lungs)in a first degree relative?* This field is required.
Yes
No
19
Which relative?
Mother
Father
Sister
Brother
Aunt
Uncle
Maternal grandmother
Maternal grandfather
Paternal grandmother
Paternal grandfather
20
Do you suffer from migraine* This field is required.
Yes
No
21
Please describe
22
Do you have a family history of diabetes mellitus in a first degree relative?
Yes
No
23
Which relative?
Mother
Father
Sister
Brother
Aunt
Uncle
Maternal grandmother
Maternal grandfather
Paternal grandmother
Paternal grandfather
24
Do you have a family history of heart disease before 60 years of age?
Yes
No
25
Which relative?
Mother
Father
Sister
Brother
Aunt
Uncle
Maternal grandmother
Maternal grandfather
Paternal grandmother
Paternal grandfather
26
Have you ever had a stroke or transient ischaemic attack (mini-stroke)?* This field is required.
Yes
No
27
Do you have a family history of stroke or transient ischaemic attack (mini-stroke)?
Yes
No
28
Which relative?
Mother
Father
Sister
Brother
Aunt
Uncle
Maternal grandmother
Maternal grandfather
Paternal grandmother
Paternal grandfather
29
Have you ever had breast cancer?* This field is required.
Yes
No
30
Do you have a family history of breast cancer?
Yes
No
31
Which relative?
Mother
Father
Sister
Brother
Aunt
Uncle
Maternal grandmother
Maternal grandfather
Paternal grandmother
Paternal grandfather
32
What is your smoking status?* This field is required.
Never smoked tobacco
Cigarette smoker
Ex-smoker
Roll my own cigarettes
Vaper / e-cigarette smoker
Other
33
I understand that smoking is damaging to health, and increases the risk of blood clots if I am also taking the combined oral contraceptive pill. I know that if I am a smoker I can contact reception to ask for help to stop smoking
Yes, I understand
34
Please read the information in these links:

Guide to the combined pill

Guide to the progesterone only pill (mini pill)

and what to do if you miss a pill:

missed combined pill

missed progesterone only pill (mini pill)

Please read this information about sexually transmitted infections. If you would like to have screening, please enquire via reception or Umbrella Health

Sexually Transmitted Infections
35
Please tick here to confirm you have read and understood the information in the links above* This field is required.
Yes, I understand
36
Please send my prescription to:
Superdrug Harborne
Boots Harborne
Jhoots Harborne
Other
37
I confirm all the information I have supplied is correct to the best of my knowledge. Signature:
Clear
Should be Empty: