Raf

About You

Are you registered with a GP practice in the UK?

Yes No

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you.)

Yes No

Do you believe you have the capacity to make decisions about your own healthcare?

Yes No

Symtoms

Have you been taking the same contraceptive pill for the last year?

Yes No

Have you had any problems or concerns with your contraceptive pill in the last year?

Yes No

Do you experience any side-effects from the contraceptive pill, particularly unexplained or irregular bleeding?

Yes No

Was your last period late, lighter, shorter or unusual in any way?

Yes No

Have you had a face-to-face pill check with your GP / Nurse in the last year.

Yes No

Health

Are you overweight?

Yes No

Have you ever had a reaction or allergy with the contraceptive pill?

Yes No

Do you currently suffer from high blood pressure (above 140/90 mmHg), diabetes or lactose intolerance?

Yes No

Do you smoke?

Yes No

What is your blood pressure?

Low (below 90/60)
Normal (between 90/60 and 140/90)
High (above 140/90)

What was the date of your last blood pressure check?

Have you ever been diagnosed with any of the following?

Blood clot in a blood vessel of your legs or other organs
Medical history of heart attack or stroke
Suffer from (or ever had) a type of migraine called 'migraine with aura'
Current or history of breast cancer
Liver disease / liver tumors
High cholesterol

Yes No

Are you pregnant or breast feeding or intending to become pregnant or start breast feeding whilst taking this medication?

Yes No

Are you up-to-date with your cervical smear tests?

Smears are required every 3 years for women 25-49 yrs and every 5 years from 50-64 yrs
You may require more regular smears if you have previously had an abnormal result

Yes No

Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes No

Are you taking any of the following medications?

Medication to treat epilepsy
Medication to treat HIV and Hepatitis C (protease inhibitors and non-nucleoside reverse transcriptase inhibitors)
Sedative medication (barbiturates)
St John's Wort (herbal)
Antibiotics
Over the counter medication

Yes No

Are you aware that you must stop taking the PILL immediately if you suffer from any of the following?

Sudden pain in the chest or stomach
Sudden or unexplained breathlessness
Loss of vision or blurring of vision
Chest pain or rapid irregular heartbeats
Swelling or severe pain in the calf of one leg
Sudden severe and prolonged headaches

Yes No

Agreement

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
I consent to being contacted by telephone or email should the pharmacist require further information to assess my order.
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

Yes No

Medical Assesment Contraceptive Pill