Contraceptive Pill Check Questionnaire

If you have been advised by the surgery to submit a contraceptive pill check questionnaire, please use this form.

Contraceptive Pill Check Questionnaire

Contraceptive Pill Check Questionnaire


Blood Pressure

This can be taken at home or at the surgery in the waiting room if you don’t have access to a machine.

About You

Are your periods regular?
Do you have any bleeding between your periods?
Do you have any bleeding after sex?
Have you needed to use emergency contraception in the last 3 months?
Are you a smoker?

For help with becoming smoke free, please visit

Have you or a blood relative family member ever had a blood clot in the leg or the lung under the age of 55?
Have you or a family member had a heart attack or stroke under the age of 45?
Do you suffer from severe headaches or migraines?
Do you ever get flashing lights, numbness or weakness with/before your headache?
Have you or a family member had Breast cancer under the age of 50 or do you carry the BRCA gene?
Do you regularly check your breasts?

We should check our breasts once a month. Please view the following leaflet for help with how to do that to help detect changes early.

Please visit

Are you concerned about a sexually transmitted infection?

You can get free STI screening by visiting

Please note hormonal contraception does not prevent STIs so we still advise condom use.

Long Acting Methods of contraception are more reliable – we fit all types of contraception at the surgery and offer local anaesthetic to all ladies for intrauterine contraception (“the coil”).

Please see the following leaflet for more information about all forms of contraception available by visiting

Combined Pill

Please read the following leaflet which covers how to take the combined pill, how the combined pill works and what to do if you miss a pill by visiting

Please tick the checkbox below to confirm that you have read the leaflet and understand:

  • The combined pill has a small increase in risk of blood clot
  • The combined pill is probably associated with a small increase in breast cancer risk
  • That spotting is common in the first few months
  • To inform your doctor if you develop new headaches after starting it
  • To inform your doctor if you start new medication
    How to take it and what to do if you have vomiting, diarrhoea or forget to take the pill.
  • Please note the modern way to take the combined pill is not to have a bleed every month.
  • The combined pill increases your risk of blood clots. You must seek urgent medical attention if you develop chest pain or leg swelling.

Progesterone Only Pill

This is different to the combined pill and has 1 hormone. It must be taken every day at the same time.

Please read the following leaflet about the progesterone-only pill by visiting