Contraceptive Pill Review

Section

About You

Height:

Current Weight:

Do you currently smoke?

Yes

No

Have you smoked in the past?

Yes

No

How many cigarettes did you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking?

Yes

No

Your Blood Pressure

Please provide your most recent blood pressure reading, if you have a monitor.

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Contraception 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

*

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

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