NHS Pharmacy Contraception Service pre-consultation Form

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All questions marked with a * are mandatory

To provide the contraceptive pill safely, we need to ask you a number of questions. Please complete this form before your consultation with the pharmacist.

If you are having any problems with your medicine or would like to consider alternative contraceptive options, please discuss this with the pharmacist.

Once this form has been submitted, your medication will be ready for collection in 48 hours.

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Personal Details
Please double check you've entered the correct email address
Have you had any contraception pill before?: *
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Screening Questions
Are you wanting to start a new contraceptive pill or restart a previously used contraceptive pill?: *
Have you previously had a supply of your contraceptive pill from your general practice, sexual health clinic or a pharmacy?:
Are you wanting to change your current contraceptive pill?:
Have you missed any pills at any point or had a gap of any duration since your last supply?:
Have you had any problems with or side effects from your contraceptive pill?:
Are you taking any other prescribed medication?: *
Are you taking any over the counter medicines or herbal products?: *
Please provide your blood pressure (must be within the last 3 months).: *
If you need your blood pressure check you can do this for free in the surgery.
Are you pregnant, or might you be pregnant?: *
Do you have long periods of immobility?: *
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Cardiovascular Health
Are you a smoker (including vaping / use of e-cigarettes) ?*: *
If you are a smoker, would you like help giving up?*: *
Do you have a current or past history of ischaemic heart disease, vascular disease, stroke, or transient ischaemic attack (TIA)?: *
Do you have diabetes?: *
Has this affected any of your organs (causing retinopathy, nephropathy, or neuropathy)?:
Have you ever had a deep vein thrombosis or pulmonary embolus?: *
Do you have a current or past history of any heart disease?: *
Do you have parents, siblings or children who have had heart disease or strokes under the age of 45?: *
Do you have parents or siblings that have had a deep vein thrombosis or pulmonary embolus under the age of 45?: *
Do you have any blood clotting illnesses / abnormalities?: *
Do you have any problems with your heart muscle or any impaired heart function?: *
Do you have or have you been diagnosed with atrial fibrillation?: *
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Neurological health
Do you suffer from migraines?: *
Do you experience visual symptoms or changes in sensation or muscle power on one side of your body?: *
If you suffer from migraines, did your first attack occur when you started taking your contraceptive pill?: *
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Cancers
Do you have any past or current history of breast cancer?:
Do you have any undiagnosed breast symptoms?: *
Do you have any family history of breast cancer under the age of 50?: *
Do you have any past or current history of any other cancer?:
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Gastro-intestinal health
Do you have any form of liver disease or liver impairment?:
Do you have gall bladder disease that causes you symptoms or is medically managed?: *
Do you suffer from acute/active inflammatory bowel disease or Crohn's disease?:
Have you had any bariatric surgery or any other surgery that has reduced your ability to absorb things from your stomach?:
Do you suffer from Cholestasis, a condition caused by blocked or reduce flow of bile fluid?: *
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Other Health Conditions
Do you have any planned major surgeries?: *
Have you ever been diagnosed with Anti phospholipid syndrome (APS) (also known as Hughes syndrome) with or without Lupus?: *
Have you ever had an organ transplant that has resulted in complications?: *
Do you have severe kidney impairment or acute renal failure?: *
Have you been diagnosed with Acute porphyria?: *

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