Oral Contraceptive Risk Assessment Form

Date

MsMissMrsDr

Name*

First NameLast Name

Telephone*

Date of Birth*

DayMonthYear

Age

Patient Address (line 1)*

Patient Address (line 2)

Line 1

GP Name

GP Address

GP Telephone (if known)

Would you like us to send a copy of this consultation to your GP?

Personal Medical History*

Rows	Yes	No
Is the contraceptive for your own use?
Do you have any recent or past medical history of note?
Do you take any current or repeat medicines?
Is there a possibility you may be pregnant?
Are you over 35 years of age and a smoker?
Are you overweight? Or have blood pressure problems? (if you are unsure, the pharmacist can check this for you)
Do you have a family history of blood clots or thrombosis?
Do you have any of the following conditions? Diabetes, migraine headaches, Cancer, HIV, high blood pressure, liver disease?

Personal Medical History*

Rows	Yes	No
Have you been taking your current contraceptive pill for more than a year?
Have you been prescribed the same contraceptive pill for more than 9 months?
Have you ever had a check up with your doctor / nurse about your contraceptive pill in the last year?
Are you having any problems with your current contraceptive pill such as irregular bleeding / periods?

Write below any further information which may be relevant e.g. medicines taking,conditions, concerns...