Public Holiday Monday 22nd July 2024

Please note we are closed Monday 22nd July 2024 If you need medical advice please call NHS 24 on 111 In a medical emergency please call 999 We will re-open Tuesday 23rd July 2024

New Contraceptive Form

(For women 16 years and over)

Please use the links to find out about the different contraceptive options before completing the questionnaire:

Contraceptive Review
Please use format day/month/year e.g. 12/05/1979

Smoking Status

Do you smoke?
How many cigarettes do you smoke a day?
Would you like help to quit smoking?
Do use an e-Cigarette

Height and Weight

Weight

Please provide details of your heigh and weight in either Metric or Imperial units.
Unit of measurement *
Choose your preferred unit of measurement.
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

Sexual, Menstrual and Obstetric History

Have you been correctly and consistently been using a reliable form of contraception?
Are your periods regular?
Are you sexually active?
Do you feel you may be at risk of a sexually transmitted infection (STI)?
Is there a risk you could be pregnant?
Have you given birth, had a miscarriage or termination in the past 6 months?
Are you currently breastfeeding?
Are your cervical smears up to date?
Have you experienced any irregular or unusual vaginal bleeding or bleeding after intercourse?

Health and Family History

Do you suffer from migraine headaches?
Do you have diabetes?
Do you have any blood clotting illnesses/abnormalities?
Have you ever been diagnosed with epilepsy?
Have you ever been told you have rheumatic disease such as lupus?
Do you have gallbladder or liver disease?
Have you noticed a new or changing breast lump?
Have you or a family member ever been diagnosed with cancer of the breast, womb or ovary?
Have you, your parents or siblings been diagnosed with heart disease or a stroke?
Have you or any family members had a deep vein thrombosis (DVT) or Pulmonary Embolus (PE)? (blood clot in leg or lung)
Are you generally immobile or struggle to mobilise e.g. wheelchair use, debilitating illness?
Have you had surgery in the past 6 months?
Do you take any medication that is NOT prescribed or that you buy over the counter?

Privacy Policy

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.