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Contraception Service Pre-consultation Questionnaire
lets get your details sent across.
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Your Details
Name
D.O.B
Sex
Male
Female
Non-Binary
Email
Contact Number
Address Details
First Line of Address
Second Line of Address (optional)
City
Postcode
GP Details
NHS Number (Optional)
GP/GP Practice Name
GP Address
Screening Questions
Are you wanting to start a new contraceptive pill or restart a previously usedcontraceptive pill?
New
Previously Used
Have you previously had a supply of your contraceptive pill from your generalpractice, sexual health clinic or a pharmacy?
Yes
No
Are you wanting to change your current contraceptive pill?
Yes
No
Have you missed any pills at any point or had a gap of any duration since yourlast supply?
Yes
No
Have you had any problems with or side effects from your contraceptive pill?
Yes
No
Are you taking any other prescribed medication?
Yes
No
Are you taking any over the counter medicines or herbal products?
Yes
No
Have you had your blood pressure checked within the last three months?
Yes
No
Please provide your blood pressure reading if known (if not known leave blank)
Are you pregnant, or might you be pregnant?
Yes
No
Do you have long periods of immobility?
Yes
No
Cardiovascular Health
Are you a smoker (including vaping / use of e-cigarettes)?
Yes
No
Would you like help giving up?
Yes
No
What is your weight?
What is your Height?
Do you have a current or past history of ischaemic heart disease, vasculardisease, stroke, or transient ischaemic attack (TIA)?
Yes
No
Do you have diabetes?
Yes
No
Has this affected any of your organs (causing retinopathy, nephropathy,or neuropathy)?
Yes
No
Have you ever had a deep vein thrombosis or pulmonary embolus?
Yes
No
Do you have a current or past history of any heart disease?
Yes
No
Do you have parents, siblings or children who have had heart disease orstrokes under the age of 45?
Yes
No
Do you have parents or siblings that have had a deep vein thrombosis orpulmonary embolus under the age of 45?*
Yes
No
Do you have any blood clotting illnesses / abnormalities?
Yes
No
Do you have any problems with your heart muscle or any impaired heartfunction?
Yes
No
Do you have or have you been diagnosed with atrial fibrillation?
Yes
No
Cancers
Do you have any past or current history of breast cancer?
Yes
No
Do you have any undiagnosed breast symptoms?
Yes
No
Do you have any family history of breast cancer under the age of 50?
Yes
No
Do you have any past or current history of any other cancer?
Yes
No
Gastro-intestinal Health
Do you have any form of liver disease or liver impairment?
Yes
No
Do you have gall bladder disease that causes you symptoms or is medicallymanaged?
Yes
No
Do you suffer from acute/active inflammatory bowel disease or Crohn’s disease?
Yes
No
Have you had any bariatric surgery or any other surgery that has reduced yourability to absorb things from your stomach?
Yes
No
Do you suffer from Cholestasis, a condition caused by blocked or reduce flow of bile fluid?
Yes
No
Other Health Conditions
Do you have any planned major surgeries?
Yes
No
Have you ever been diagnosed with Anti phospholipid syndrome (APS) (alsoknown as Hughes syndrome) with or without Lupus?
Yes
No
Have you ever had an organ transplant that has resulted in complications?
Yes
No
Do you have severe kidney impairment or acute renal failure?
Yes
No
Have you been diagnosed with Acute porphyria?
Yes
No
Disclaimer
Enter Your Full Name
Enter Todays Date
Disclaimer
By clicking Submit, you confirm that the information you have provided is true, accurate, and complete to the best of your knowledge. You consent to us using this information to deliver any relevant services and to securely store your details in line with data protection requirements. You also agree that we may use your contact information to communicate with you regarding any current, ongoing, or previous services or appointments with us.
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