Annual Pill Check Questionnaire

Pill check Questionnaire

Name Required

First Last

Date of Birth Required

Please provide us an up to date body weight Required

Please provide us an up to date blood pressure. OptionalIf you cannot provide this then please visit your local Pharmacy who can check this or contact us. This is required for your annual review.

3. Have you suffered any Migraines/headaches since your last check-up? Required

Have you had any significant illnesses or hospital admissions since your last review? Required

What is your current smoking status? RequiredIf you currently smoke please let us know how many a day.

Do you have questions or comments in regards to your current contraception? Required

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Annual Pill Check Questionnaire

Pill check Questionnaire

Additional Information