Combined Oral Contraceptive Review Form

Combined Oral Contraceptive Review Form

If you have been advised by the surgery to submit a combined oral contraceptive review form please use this questionnaire.

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Please Answer All of the Following Questions

    What is your current smoking status?
    Do you suffer from migraines with aura, or a headache associated with weakness or numbness on one side of your face or body, disturbance of your vision, or difficulty with speech?
    Have you been diagnosed with any of the following conditions in the past 12 months?
    Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following medical conditions at any point in the past
    In the past 12 months, have you suffered from any unexpected vaginal bleeding, such as between periods or after sex?
    As far as you are aware, are you up to date with your cervical smear test?
    Are you currently taking any of the following medications?
    Do you frequently forget to take you pill during each monthly cycle?
    Are you happy with your current method of contraception, or would you like to change to something else?
    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.
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Page last reviewed: 27 February 2026
Page created: 27 February 2026