Flu and COVID Vaccinations – Autumn / Winter

Flu / COVID season is here! There are some changes regarding when patients will be eligible for their Flu / COVID vaccinations this year. Please visit our Flu / COVID page to read all of the updates. We are now inviting eligible patients to book their appointments.

Portsdown Group Practice > Forms > Health Review Forms > Contraceptive Pill Check Form

Contraceptive Pill Check Form

If you are aged over 16 years and require a prescription for your pill, please complete this form IN FULL as incomplete forms may not be processed and will cause a delay in processing your request. Please utilise the scales and BP machine within the POD located at reception.

Contraceptive Pill Check
Please use format day/month/year e.g. 12/05/1979

Height and weight

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

Blood pressure

Your blood pressure reading is made up of 2 numbers. Enter the highest number first. This is the highest level your blood pressure reaches when your heart beats (systolic). Then enter the lower number. This is the lowest level your blood pressure reaches when your heart relaxes between beats (diastolic).

Your health

Have you given birth in the past 12 weeks?
Are you breastfeeding?
Do you have a family or a personal history of blood clots? (DVT or pulmonary embolism)
Have you had any NEW irregular bleeding or change to your bleeding pattern?
Have you had any bleeding after sex?
Are you up to date with your smear test?
Do you suffer from NEW/CHANGING migraines?
Do you feel at risk from abuse or violence?
Smoking status
How many cigarettes do you smoke each day?
Are you aware that smoking alongside taking some contraceptive pills increases you risk of blood clots?
Are you aware that a Stop Smoking service is available via the Wellbeing service (02392 29401)?
Do you drink alcohol?

Alcohol Consumption

Units of Alcohol

chart showing alcohol units

Automatically calculated
Are you aware that long acting reversible contraception (coil, implant, injection) is available as a more reliable method of contraception than the pill?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.