Combined Pill Review

High Blood Pressure readings
UKMEC >3

Advise review of BP and consideration of different contraception.

Blood Clot or Migraine with Aura
UKMEC >3

Advise review with clinician and changing method of contraception.

Stroke or Heart Condition
UKMEC >3

Advise review with clinician and changing method of contraception.

Breast Cancer Risk
UKMEC >3

Advise review with clinician and changing method of contraception.

Age >35 + Smoker
UKMEC 3

Advise review with clinician and changing method of contraception.

BMI Over 35
UKMEC 3

Advise review with clinician and changing method of contraception.

BMI lower than 19
Patient is likely underweight.  Advise actioning form as usual but forward to clinician for review of weight.

BMI lower than 19
Patient is likely underweight.  Advise actioning form as usual but forward to clinician for review of weight.

Please complete this form to help us review your prescription for the Combined Pill.

This pill type includes Rigevidon, Levest, Gedarel, Microgynon, Yasmin, Loestrin and many more!

To ensure you are at low risk of problems with this pill, we need you to provide your HEIGHT, WEIGHT and BLOOD PRESSURE (unless done recently in the practice). If you are unable to measure these at home please arrange to have these done at the practice. 0131 333 3215

Your Details

Please confirm that you have considered the benefits and risks of the combined pill

Blood Pressure (within the past 12 months)

OR

Height and Weight

Units

Metric

Imperial

Height

Weight

Do you smoke?

Smoking is the most common cause of high BP, heart attacks and stokes. We STRONGLY advise stopping.

There are NHS smoking clinics in Edinburgh and West Lothian to help you stop.

Have you ever had a blood clot or a migraine with aura?
Have you had a stroke or suffer from a heart condition?
Have you had breast cancer or have a high risk from genetic testing (BRCA)?

Have you considered more reliable contraception such as the Coil, Implant or Injection? (see below)

COIL Information
IMPLANT Information
INJECTION Information

Are you happy with your pill?
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.
Consent

© 2022 Kristian Turnbull