Contraceptive pill review

Height

In Metres

Weight

In KG

Do you regularly check your breasts?

Yes

No

Please ask reception for our information regarding the importance of regular breast self-examination.

Do you suffer from severe headaches or migraines?

Yes – But the Doctor is unaware

Yes – But the Doctor is aware

No

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Are you experiencing any irregular bleeding?

Yes

No

Please book an appointment to see the practice nurse

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate:

I confirm that the information provided is accurate to the best of my knowledge

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