WIGSTON CENTRAL SURGERY	Date Received	
	 Pill Check Review		

Thank you for completing this form.  We are aiming to avoid the need for you to see a clinician in order to re-issue your pill prescription.  Once completed, please hand the form to reception and we will generate your next 3/6/12 month supply of the contraceptive pill.  Scales and a blood pressure machine can be found in the waiting area – we are unable to issue a repeat prescription without up to date blood pressure and weight measurements.  Please note, it will take 72 hours to generate your prescription.

PERSONAL DETAILS	
Full Name   
	Telephone Number 	
Mr/Mrs/Miss/Ms/Other 
	Work Number	
Address and Postcode	Mobile Number
	
	E-mail Address
	
Date of Birth
		
Height	Feet/inches
	cm	Weight	Stones/lbs	kg	
Blood Pressure Reading 1 (Please use the machine next to the patient lift, at the surgery. Take 2 readings ,5 minutes apart)	Blood Pressure Reading 2 

	
MEDICAL HISTORY	

Please circle or tick your answers.  If you answer yes to any of the following questions, we may contact you to discuss further.  
	
Have you had any problems or concerns with the pill?	Yes / No	
Are you breast feeding?	Yes / No	
Do you suffer from migraines?	Yes / No	
Do you have a family or personal history of DVT or pulmonary embolism?	Yes / No	
Have you had any irregular bleeding?	Yes / No	
	
Do you smoke?
(please tick 1 box only)	Current Smoker	Ex-Smoker	Never Smoked

How often do you have an alcoholic drink? 

(please tick 1 box only)	Never
	Monthly or less	2-4 times per month	
	2-3 times per week	4+ times per week		
How many standard* alcoholic drinks do you have on a typical day when you are drinking?
(please tick 1 box only)	1-2 drinks
	3-4 drinks	5-6 drinks	
	7-9 drinks
	10+ drinks		
How often do you have 6 standard* alcoholic drinks on one occasion? 
(please tick 1 box only)	Never
	Less than monthly	Monthly	
	Weekly
	Daily or almost daily		
*  A standard alcoholic drink is 1 unit of alcohol – a small glass of wine, a pub measure of spirits or ½ pint of lager/beer	

	

Name of requested contraceptive pill:		
Signature of patient:	Date:	
For office use:

Issue repeat prescription for      3       6       12     months (circle as appropriate)                                                                                                                                 
Issue repeat prescription for 1 month and then review:                                             
Needs review with GP: 	                                                                   	
Needs review with Practice Nurse:                                                    	
Signed: …………………………………
(GP/Nurse)

Date: ……………………………………