Contraceptive Pill Review If you have been advised by the surgery to submit a contraceptive pill review please use this form. Contraceptive Pill Review Contraceptive Pill Review About You Full Name: * Date of Birth: * Please use this date format: DD/MM/YYYY. Phone Number: Email Address: * Contraception Pill Review Do you regularly check your breasts? Yes No 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 Yes - But the Doctor is aware No 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 No Please book an appointment to see the practice nurse
