NHS Pharmacy Contraception Service pre-consultation questionnaire
To provide the contraceptive pill safely, we need to ask you several questions. Please complete this form before your consultation with the pharmacist or pharmacy technician
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
Please enter a valid phone number.
Format: (0000) 000-0000.
Email
example@example.com
GP Practice
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Screening Questions
Current or previous contraception used?
Pill
Patch
Intrauterine Device (IUD) or Copper Coil
Intrauterine System (IUS)
Injection
Implant
Vaginal Ring
Want to start a new contraceptive or restart contraceptive pill?
Yes
No
Previous supply from GP/clinic/pharmacy?
Yes
No
Name of Pill?
Do you use the contraceptive pill mainly for contraceptive purposes?
Yes
No
If no, please indicate the reason it was prescribed:
Areyou wanting to change your current contraceptive pill?
Yes
No
Not Sure
Have you missed any pills at any point or had a gap of any duration since your last supply?
Yes
No
Have you had any problems with or side effects from your contraceptive pill?
Yes
No
Are you taking any other prescribed or supplied medication, including short term medication (e.g. antibiotics)?
Yes
No
Are you taking any over the counter medicines, herbal products or supplements?
Yes
No
Please provide details of prescribed, counter medication, herbal products or supplements
Do you have any allergies?
Yes
No
Please specify allergies
Are you using any medication or have you had any surgery to assist with weight loss?
Yes
No
Have you had your blood pressure checked within the last three months?*
Yes
No
Please provide reading
Are you pregnant, or might you be pregnant?
Yes
No
Have you given birth to a child in the last 21 days?
Yes
No
Are you breast feeding?
Yes
No
Do you have long periods of immobility?
Yes
No
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Cardiovascular health
Are you a smoker (including vaping / use of e-cigarettes)?
Yes
No
What is your weight?
What is your height
Do you have a current or past history of ischaemic heart disease, vascular disease, stroke, or transient ischaemic attack (TIA)
Yes
No
Do you have diabetes?
Yes
No
If yes, has this affected any of your organs (causing retinopathy, nephropathy, orneuropathy)?
Yes
No
Have you ever had a deep vein thrombosis or pulmonary embolus?
Yes
No
Do you have a current or past history of any heart disease?
Yes
No
Do you have parents, siblings or children who have had heart disease or strokes under the age of 45?
Yes
No
Do you have parents or siblings that have had a deep vein thrombosis or pulmonary embolus under the age of 45?*
Yes
No
Do you have any blood clotting illnesses / abnormalities?*
Yes
No
Do you have any problems with your heart muscle or any impaired heart function?
Yes
No
Do you have or have you been diagnosed with atrial fibrillation?*
Yes
No
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Cancers
Do you have any past or current history of breast cancer?
Yes
No
Do you have any undiagnosed breast symptoms?
Yes
No
Do you have any family history of breast cancer under the age of 50?*
Yes
No
Do you have any past or current history of any other cancer?
Yes
No
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Neurological health
Do you suffer from migraines?
Yes
No
If so, do you experience visual symptoms or changes in sensation or muscle power on one side of your body?*
Yes
No
If you suffer from migraines, did your first attack occur when you started taking your contraceptive pill?*
Yes
No
Do you have a meningioma or a history of meningioma?
Yes
No
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Gastro-intestinal health
Do you have any form of liver disease or liver impairment?
Yes
No
Do you have gall bladder disease that causes you symptoms or is medically managed?*
Yes
No
Do you have gall bladder disease that causes you symptoms or is medically managed?*
Yes
No
Do you suffer from acute/active inflammatory bowel disease or Crohn’s disease?
Yes
No
Have you had any bariatric surgery or any other surgery that has reduced your ability to absorb things from your stomach?
Yes
No
Have you had any bariatric surgery or any other surgery that has reduced your ability to absorb things from your stomach?
Yes
No
Do you suffer from Cholestasis, a condition caused by blocked or reduce flow of bile fluid?*
Yes
No
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Other health conditions
Do you currently have any undiagnosed vaginal bleeding?
Yes
No
Do you have any planned major surgeries?*
Yes
No
Do you have any kidney impairment or acute renal failure?*
Yes
No
Have you been diagnosed with Acute porphyria?
Yes
No
Is there anything else you would like to share with us to consider in your consultation?
Yes
No
Any other information please state here
Submit
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