Oral Contraceptive Review

Please only complete the following questionnaire if requested by your GP practice as part of your routine oral contraception review.

Oral Contraceptive Review

Oral Contraceptive Review

This questionnaire is for a routine review of your use of contraception. If you are experiencing any of the following, ring your GP immediately.

  • A bad headache, or worsening or changing migraines
  • Painful swelling of the leg
  • Weakness if numbness of an arm or leg
  • Sudden problems with your speech or sight
  • Difficulty breathing
  • Coughing up blood
  • Pains in your chest, especially if it hurts to breathe in
  • A bad pain in your tummy (abdomen)
  • A faint or collapse

About You

In Metres

Blood Pressure

Have you been experiencing side effects since you started taking the pill? *
Do you suffer from severe headaches or migraines? *

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Have you ever had any blood clots? (eg. Deep vein thrombosis or pulmonary embolism) *
Have you ever had a heart attack or stroke? *
Have you ever had breast cancer or cervical cancer? *
Have you considered other types of contraception? *
Do you have a family history of any of the following? (Please select all that apply)
I understand the benefits and risks of oral contraception: *
Would you like any further information about Long Acting Reversible Contraception (eg. contraceptive implant or coil)? *
Please select the options you are interested in below:

If you would like more information about Long Acting Reversible Contraception, please visit www.fpa.org.uk/download/your-guide-to-larc/


This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *


Do you smoke? *
Do you use an e-cigarette?

Would you like help to quit smoking?

Please visit NHS Smokefree for help and advice for quitting smoking.

Further Questions