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.
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Blood Pressure - systolic (high number) / diastolic (low number), eg. 120/80
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Are you experiencing any side effects?
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If yes, please describe these side effects below:
Have you missed any pills?
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If yes, how often do you miss a pill?
Do you know what to do if you miss a pill?
Have you given birth within the last 6 weeks, or are you breastfeeding?
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Do you suffer from migraines or severe headaches?
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If yes, is your doctor aware of this?
Have you, or a close family member ever had a blood clot in the leg or lung?
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Have you ever noticed a new or change in breast lump, or been diagnosed with breast cancer? If you have a breast lump or a strong family history of breast cancer, and have not previously discussed this, please make an appointment with a clinician.
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Do you carry out regular breast checks? We strongly recommend that all women should be breast aware. If you are unsure how to do this, contact the practice nurse for advice.
Are you experiencing any irregular vaginal bleeding?
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If you are between 25 - 64years old, have you had a cervical screening (smear) test within the last 5 years?
If yes, how much do you smoke per day? We advise all smokers that they should stop smoking. Smoking increases the risk of circulatory problems, particularly in women who take the pill. If you would like to stop smoking, your local community pharmacy can advise you through the 'smoking cessation service'.
More women are becoming interested in using long acting reversible contraception - e.g. injection, implant or coil. Would you like to consider one of these methods?
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Surgery use: DATA INPUT DATE - INITIALS -