Combined Oral Contraceptive Pill COCP questionnaire

Name

Date of birth

E mail

Telephone number

Mobile number

Do you know the name of the contraceptive pill that you want?

What is the name of the contraceptive pill you are requesting a repeat prescription for?

Have you started taking any new regular medications or health supplements (e.g. St John's Wort) recently?

What are the names of the new regular medications or health supplements (e.g. St John's Wort) that you have started taking since your last prescription?

Have you been diagnosed with any new health conditions since we last issued you a prescription for the pill? These could be any conditions but in particular: heart disease, stroke, breast cancer, liver disease.

What new health conditions have you been diagnosed with since your last prescription?

To ensure prescribing the pill is safe, please answer the following questions about medical issues that you may have or that run in your family.

Are you getting new or worsening headaches?

Do you get migraines?A migraine is usually a moderate or severe headache felt as a throbbing pain on one side of the head. For more information about migraines

Please describe your headaches

Do you have an aura with your migraines?An aura is where you have warning signs before your headache begins such as changes to your vision or numbness/pins and needles.)

Have you ever had a blood clot (also known as DVT/PEs)?These are clots that cause swollen and painful arms, legs or chest pain.

Have any of your immediate family ever had a blood clot (DVT/PE)?Your immediate family includes your father, mother, brother and sister

Have any of your immediate family or second degree relatives ever had breast cancer?Your immediate family include your father, mother, brother or sister. Your second degree relatives include your aunts, uncles, nephews, nieces, grandparents and grandchildren

Which relatives had breast cancer? Approximately, what age were they diagnosed with it?

Do you have any new unexpected bleeding between your periods since your last review?

Do you have any new bleeding after sex since your last review?

Are you up-to-date with your cervical screening (smear test)?

Are you interested in having any sexual health screening?This could be important as the oral contraceptive does not protect against sexually transmitted infections

What is your smoking status?

If a current smoker, how much do you smoke?

To safely prescribe the contraceptive pill, it is important that we have an up-to-date blood pressure reading.

Are you able to provide a blood pressure reading?

If yes, please enter the readings below

Please enter your systolic (SYS) blood pressure reading. This is the top reading.

Please enter your diastolic (DIA) blood pressure reading. This is the lower reading. Note: This is NOT the pulse.

Do you know your weight?

Please enter your weight in kilograms.

Do you know your height?

Please enter your height in metres.

Are you having any side effects or problems from your contraceptive pill that you would like to discuss with your GP/nurse?

Is there anything else regarding the contraceptive pill that you would like us to know?

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