Prescriptions: Contraceptive Review "Pill Check" & Medication Review

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

You will need an up to date weight and blood pressure.

Information on various contraceptive can be found below:

It is advised where possible to consider long acting contraceptive options like the implant or coil. To find out more information or book your appointment for long acting contraception see below:

Coil & Implant

Antidepressant review mood questionnaire calculator

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 3 working days to complete. Please DO NOT call before 3 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Prescriptions: Contraceptive Review "Pill Check" & Medication Review

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

Do you suffer from migraine headaches?

What form of contraception are you currently using?

Would you like to continue with your current method?

If no, why not? And which alternative would you like to use?

Prescription details

If approved which pharmacy would you like us to send your prescription too?

If other please state pharmacy name & postcode

I confirm I have read through the links above which relate to my contraception option and understand what to do if I miss a dose or experience diarrhoea/vomiting

I understand that condoms are the only method of contraception that protects against Sexually Transmitted Infection; And that whilst it may not suit me at the moment I have considered a longer acting method of contraception (e.g. implant or coil)

Do you have any concerns or side effects from your medication?This relates to all your medications if you are on more then just the oral contraceptive. Please state the medication and the side effect. E.g. Paracetamol: Constipation

Do you know when and how to take your medication?

Are you on any antidepressant medication?If you are struggling with your mental health please contact the practice or if out of hours or in an emergency call the CRISIS team: 0300 200 0011 and select option 1.

If you are on antidepressants, can you please select the option which best applies to you?

Please state what score you calculated on the mood questionnaire PHQ-9 (LINK ABOVE). Please note that if your mental health is currently significantly impact and you are concerned for your well-being you must contact the crisis team on 0300 200 0011 and select option 1 or 999.

Thank you for completing this form

I confirm that the information provided is accurate to the best of my knowledge

Do you take an over the counter, herbal remedies or specialist medication? If no write: NO. If yes, please state the name and dose of these medications.

It is important that you complete a cervical smear regularly.

under 25 up to 6 months before you turn 25

25 to 49 every 3 years

50 to 64 every 5 years

65 or older only if 1 of your last 3 tests was abnormal

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