Contraceptive Pill Repeat form

Contraceptive Pill Repeat Questionnaire

First Name

Surname

Date Of Birth

NHS Number

Address

Address Line 1

Address Line 2

City

Postcode

1. Are you requesting a repeat supply of the same contraceptive pill you currently use?

Yes

2. What is the name and strength of your current contraceptive pill?

3. How long have you been taking this contraceptive pill?

4. Have you missed any pills, started a new pack late, or had vomiting or severe diarrhoea that may have affected your pill?

Yes

6. What is your latest blood pressure reading, and when was it measured?

7. What are your current height and weight?

8. List all medicines, supplements and herbal products you currently take (or write “None”).

9. List any medicine allergies, serious side effects, or current concerns with your contraceptive pill (or write “None”).

Consent

I confirm the information provided is accurate.

I do consent to assessment and GP notification where appropriate.

I understand this questionnaire must be reviewed before an appointment or supply can be confirmed.

Mobile Number

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