Combined Pill Review High Blood Pressure readingsUKMEC >3 Advise review of BP and consideration of different contraception. Blood Clot or Migraine with AuraUKMEC >3 Advise review with clinician and changing method of contraception. Stroke or Heart ConditionUKMEC >3 Advise review with clinician and changing method of contraception. Breast Cancer RiskUKMEC >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 Patient Name * Date of Birth * Age * Mobile number * Email (If you’d like a copy of your review) Please confirm that you have considered the benefits and risks of the combined pill Yes Blood Pressure (within the past 12 months) High/Top Number Low/Bottom Number OR Recently done in the practice and it was normal Height and Weight Units * Metric (kg and cm) Imperial (Stones and feet) Metric Height (cm) * Weight (kg) * Your BMI Imperial Height Feet * Inches Weight Stones * Pounds Your BMI (Imperial) Do you smoke? * YES No 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? * YES – The practice will contact you No Have you had a stroke or suffer from a heart condition? * YES – The practice will contact you No Have you had breast cancer or have a high risk from genetic testing (BRCA)? * YES- The practice will contact you No Have you considered more reliable contraception such as the Coil, Implant or Injection? (see below) * I am not interested in long acting contraception I would like to DISCUSS this with a clinician COIL InformationIMPLANT InformationINJECTION Information Are you happy with your pill? * Yes, please CONTINUE my pill for the next year No, I would like to DISCUSS this with a clinician 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 * I agree to the privacy policy © 2022 Kristian Turnbull Submit If you are human, leave this field blank.
