Contraceptive Pill Review

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

Please be aware that any replies from the surgery may appear in your junk or spam inbox.

There are many types of contraception available and none are perfect. The Contraception Choices website provides honest information to help weigh up the pros and cons.

Contraceptive Pill Review

Contraceptive Pill Review

Section

Is this your up to date telephone number? *

Contraception Pill Review

In Metres
In KG
Would like to be referred for help with weight loss?

Blood Pressure

Please check blood pressure at home or in the surgery using our self service machine (no appointment needed)

To find a local pharmacy that does blood pressure readings, please visit the following websites:

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Please use this date format: DD/MM/YYYY.
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We would like to invite you to attend a Sexual Health Screening, just a quick discreet 15 minutes appointment. The screening we provide is for Chlamydia, Syphilis, Gonorrhoea and HIV. By participating to screening, you will be giving us consent to refer you to the ICash Sexual Health Clinic in Norwich if you receive a positive result for Syphilis, rectal Chlamydia, Gonorrhoea or HIV, for appropriate treatment and follow up. Other positive Chlamydia will be treated at the surgery which will include contact tracing. You can choose to receive your results by either text message or letter.

Would you like to attend a Sexual Health Screening? *
Smoking status: *

Please visit our Stop Smoking Page in our Wellbeing Centre for advice on smoking and how to quit.

Do you regularly check your breasts? *

Please ask reception for our information regarding the importance of regular breast self-examination.

Do you suffer from severe headaches or migraines? *

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Are you experiencing any irregular bleeding? *

Please book an appointment to see the practice nurse

Would a long-acting contraception such as coils, implants or the depo injection be of any interest to you? *
Do you have a close relative with a history of blood clots?
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