Progesterone Only Pill Self Review - Hereford Medical Group

You will need a review of your progesterone only contraceptive pill (pop) before being issued with a further supply. This form is to ensure an uninterrupted supply of medication and avoid unnecessary visits to your doctor. This is your opportunity to flag any problems to us by answering a few short questions.

If you would like to continue on this method of contraception and do not feel that you need to see a clinician, please answer the questions below so that your prescription can be renewed if appropriate.

Personal Details

Full Name:

Date of Birth:

Email Address:

Phone Number:

Security question (used to identify you)Have you had an operation in hospital? Can you remember when and what it was for?

Review Questions

Current Weight:

Height:

If you have access to a blood pressure machine, please enter your most recent blood pressure reading:

What is your smoking status?: Optional

How many do you smoke per day?: Optional

Average weekly alcohol intake in units: Optional

Are you happy with your current pill?: Optional

Do you get any problem bleeding with your current contraception?: Optional

Do you ever forget to take your pill?: Optional

Would you like to discuss going onto a more long term alternative such as an implant, injection or coil?: Optional

Do you have a family history of breast cancer?: Optional

Do you check your breasts regularly?: Optional

Do you attend for cervical screening?: Optional

Do you take any medications regularly that we do not prescribe, for example, herbal medicines?: Optional

Thank you for your feedback.