Pill Review Form

Submit this form to the team at Claremont Medical Practice in Exmouth.

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Please select an option to continue: *

Please complete your details below and you will be added to the waiting list and the practice will contact you when an appointment is available

This form can also be completed through our online services

For your safety, to be able to apply for a repeat prescription annually

You must have had your blood pressure and weight measured in the last year, please use a home BP machine or the self-monitoring machine in the waiting room.
You must have had a cervical smear test within the last three years if you are aged 25 or over.

If you would you like an STI test please contact the surgery to arrange one or call 01392 276892 (Sidwell street sexual health clinic).

Statements

If you are aged 25 or over, have you had a cervical smear test with in the last three years: *

Are you aware how the pill works?: *

Are you aware of the side effects and risks of taking the pill?: *

Are you aware that you should NOT SMOKE when taking the pill as this increases your risk of having a stroke: *

Are you aware of what to do if you miss a pill?: *

Are you aware that the contraceptive pill may not work if you vomit within 2 hours of taking the pill or have severe diarrhoea: *

Are you aware that the contraceptive pill does NOT protect you from sexually transmitted infections: *

So it is advisable to use condoms or get a STI screen with new partners

Are you aware there are different ways to take the combined oral contraceptive pill: *

You have answered No to one or more of the questions above,

Please use the resources below to find out more information. If you are then still not confident enough to answer Yes to any of the questions above, please arrange an Accurx or telephone appointment

INFO ON RISKS, DRUG INTERACTIONS & SIDE EFFECTS

Contraception Pill Review

Do you have any problems with using your contraceptive pill or side effects from the pill : *

Do you have any health matters you wish to discuss with your GP or Practice Nurse : *

Do you have migraine headaches, severe headaches or frequent headaches: *

Do you have Bleeding between periods: *

Do you have bleeding during or after sexual intercourse: *

Do you have unusual discharge : *

Do you have history of thrombosis (blood clots in veins or lungs) or a family history of clots : *

Do you have any family history of breast cancer: *

Do you smoke: *

You have answered Yes to one or more of the monitored questions above, please arrange an Accurx or telephone appointment

Health Questions

Blood Pressure: *

Please indicate whether you have used feet, inches, metres or centimetres)

Please indicate whether you have used stones, pounds or kilogrammes

Personal Details

Please double check you've entered the correct email address

May be used to identify you

Which surgery are you registered with?: *

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Pill Review Form

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EXMOUTH HEALTH CENTRE

UNDERHILL SURGERY

DEMENTIA FRIENDLY PRACTICE

RALEIGH SURGERY

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