PIll Check



Queens Bower Surgery


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Contraceptive Pill Checklist


​​ In order to provide the contraceptive pill safely we need to ask you a number of questions. We would be grateful if you could complete this form when you submit your next repeat prescription request. If you are having any problems with your medication or would like to consider alternative contraception options, please speak to one of our Practice nurses, who will be able to advise you, or refer you to the Doctor as appropriate.


Date :​​ 

Contact Number:

​​ (That you are happy for us to contact you on, if there are any queries)​​ 

1. Have you had your blood pressure checked here within the last year? Yes No

​​ 2. Are you a smoker (if 35 or over and smoker – then cant use combined pill)? Yes No​​ 

3. Would you like help giving up smoking? Yes No​​ 

4. What is your weight approximately? ___________​​ 

5. Are you aware:​​ 

a) How the pill works? Yes No

​​ b) What to do if you miss a pill (https://queensbowersurgery.co.uk/?page_id=4271) ? Yes No​​ 

c) That the contraceptive pill may not work if you have diarrhoea ,have been vomiting or are on antibiotics.​​ 

Yes No

d) That the contraceptive pill does NOT protect you from sexually transmitted infections, so you will need to use a condom as well to protect yourself.. Yes No

e) Do you suffer from migraines? Yes No If so, do you experience visual symptoms or changes in sensation or muscle power on one side of you body? Yes No

​​ f) Do you have parents or siblings who have had heart disease or stokes under the age of 45? Yes No g) Do you have diabetes? Yes No​​ 

h) Have you had a deep vein thrombosis or pulmonary embolus? Yes No​​ 

i) Do you have parents or siblings that have had a deep vein thrombosis or pulmonary embolous under the age of 45? Yes No​​ 

j) Do you have any blood clotting illnesses / abnormalities? Yes No​​ 

k) Do you have any family history of breast cancer under the age of 50? Yes No​​ 

l) Are you aware of the alternatives such as long acting reversible Yes No contraception (please read the attached pages)​​ 


We do not fit coils or implants. Please contact https ://www.nuh.nhs.uk/our-services/services/sexual-health-senice/our-clinics/ An interactive map of these clinics can be found on this separate webpage. To book an appointment for any of these clinics please phone 01159 627 627.


Thank you for completing this form. If there are any problems with re-issuing your prescription we will contact you.​​ 


Long-acting Reversible Contraception (LARC)

​​ Long-acting reversible contraceptive (LARC) devices are birth control methods that provide effective contraception for an extended period of time. You do not have to think about contraception on a daily basis or every time you have sex, as with the oral contraceptive pill or condoms. Long-acting reversible contraception is highly effective in preventing unintended pregnancies, and can be stopped if you decide you want to get pregnant.




You can download the form and get it back to us.

Contraceptive Form

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