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Medication
Review Form

Progesterone Only Pill Review

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03300 536456

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Progesterone Only Pill Review Form

Required fields are marked with an asterisk (*).

Please note:

If you are aged 55+, please book a face-to-face appointment
Age 50+ and would like to discuss how long you have taken your pill, please make a face-to-face appointment

If you are looking to start a family, we would encourage you to start taking folic acid when you stop your pill.

Your Contact Details

Name

First

Last

Date of Birth*

Email address*

Phone Number*

Which pharmacy would you like your prescription sent to?*

HEALTH CHECK

Height (in CM)*

Weight (In KG)*

Phone Number*

Do you smoke?*

Yes

No – Never smoked

No – Ex smoker

If yes how many per day?

Have you ever had breast cancer?*

Yes

Is your cervical smear up to date?*

Yes

Unsure

PILL-RELATED QUESTIONS

Name of current pill*

Are you happy to continue on your current pill?*

Yes

Have you experienced any side effects?*

Are you aware of late/missed rules?*

Yes

Are you aware that if you vomit within 2 hours of taking your pill, it may not be effective?*

Yes

Do you struggle to remember to take your pill?*

Yes

If you answered yes to the above, would you like an appointment to discuss other potential methods of contraception, such as implants, coils etc?*

Yes

Are you concerned about any abnormal bleeding (bleeding between periods or during/after sex)? *

Yes

What length of prescription would you like? *

3 months

6 months

1 year

Do you feel safe in your relationship?*

Yes

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 submitted data.

I consent to the practice collecting and storing my data from this form

Are you human?*