Contraceptive Pill Review Form Name First Last Date of Birth Day Month Year PhoneEmail Enter Email Confirm Email Height In Metres Weight In KG Contraception Pill ReviewDo you regularly check your breasts? Yes Optional No Optional 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 Optional Yes – But the Doctor is aware Optional No Optional 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 Optional No Optional Please book an appointment to see the practice nurse. I confirm that the information provided is accurate to the best of my knowledge
