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St Mary's Surgery NHS GP Surgery in Andover

Contraceptive pill review (no break)

Contraceptive Pill Review (No Break)

Section

Contraception Pill Review

Height: *

Weight: *

Smoking Status: *

Smoker

Ex-Smoker

Non-Smoker

How many do you smoke a day? *

1-9

10-19

20-39

40 or more

If you would like help to quit smoking, please visit www.smokefreehampshire.com.

How many did you smoke a day? *

1-9

10-19

20-39

40 or more

Blood Pressure (machine available in waiting area if required)

Do you regularly check your breasts? *

Yes

Please ask reception for our information regarding the importance of regular breast self-examination or visit Visit www.breastcancercare.org.uk for more information.

Are you aware of the Missed Pill Rules? *

Yes

Visit www.fpa.org.uk for more information.

Do you take any Over the Counter Medication that we may not be aware of? *

Yes

Please detail:

Is there any other information that you feel the Clinician should know?

I confirm that the information provided is accurate to the best of my knowledge

If you are human, leave this field blank.