Yearly Contraceptive Review

If you have been advised by the surgery to submit a Yearly Contraceptive Review, please use this form.

This form is for patients who have had the pill/contraception continuously for the last 6 months or longer and are aged 18 years to 55 years

Yearly Contraceptive Review

Yearly Contraceptive Review

Please use this date format: DD/MM/YYYY.

Health Questionnaire

Please leave blank if unknown.
Smoking Status: *
If you smoke, we strongly advise you to stop. If you would like help with this, please speak to reception about our in-house clinic.
Do you drink alcohol:
(1 unit = small glass of wine or half pint beer)
Please enter a recent blood pressure reading:

Contraception Questionnaire

Eg. Microgynon Pill, IUD Coil etc.
If over 25, have you had a smear test in the last 3 years?
Please book in at reception to book your next smear test.
Do you have a history of migraines or severe headaches?
Do you have problems with forgetting to take your pills?
We will contact you to discuss this.
Have you ever had a stroke, a blood clot in your legs or your lungs, a heart attack or any heart problems?
Has your mother, father, brother or sister had a blood clot in their legs or lungs aged under 60 years?
Has your mother, father, brother or sister had a heart attack or stroke aged under 60 years?
Have you or any family member had womb or cervical cancer?
Have you, or anyone in your family, had cancer of the breast?
Do you self-examine your breasts regularly?
Have you been given information about long acting reversible contraceptives (implants, coils, injections)?

If you would like more information, please see, or book to discuss these options with our pharmacist/doctor.

Would you like a sexual health screen? Please see for further details.

Informed Consent