Oral Contraceptive Risk Assessment Form

Date

Title *

Ms Miss Mrs Dr

Name *

First Name Last Name

Telephone *

Date of Birth *

Day Month Year

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 *

	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 *

	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...