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NHS Pharmacy Contraceptive Service Pre-Consultation Form

To provide the contaceptive pill safely, we need to ask you a number of questions.

We can now provide the contraceptive pill via the pharmacy free of charge without the need for women to see their GP.

We can provide the contraceptive pill free of charge:

If you been prescribed a contraceptive pill before or

If you have never taken a contraceptive pill and would like to discuss your contraceptive options.

To provide your contraceptive pill safely, we need to ask you a number of questions and may need to do a couple of checks like your blood pressure or weight, to ensure it is appropriate to make a supply to you.

Please complete the form below before having a consultation with the pharmacist.

The pharmacist will review your details and contact you to arrange a convenient time to complete any checks or collect your supply.

If you are having any problems with your medicine or would like to consider alternative contraceptive options, please discuss with the pharmacist.

See the links below at the bottom of the page for more information about the different types of contraception, contraceptive advice, links and guidance

NHS Pharmacy Contraception Service Pre-Consultation Questionnaire

Name

Address

Postcode

Date of birth

Age

Telephone number

NHS number (if known)

Ethnicity

GP Practice (if known)

Have you been prescribed/supplied with a contraceptive pill before?

--Select--

Previous contraceptive prescribed (if known)

Do you know the type of pill you have had previously?

--Select--

Previous Quantity Prescribed

What is your availability if further checks are required such as blood pressure or weight measurement?

Screening questions

1. Are you wanting to start a new contraceptive pill or restart a previously used contraceptive pill? (If yes, go to question 6)

--Select--

2. Have you previously had a supply of your contraceptive pill from your general practice, sexual health clinic or a pharmacy?

--Select--

3. Are you wanting to change your current contraceptive pill?

--Select--

4. Have you missed any pills at any point or had a gap of any duration since your last supply?

--Select--

5. Have you had any problems with or side effects from your contraceptive pill?

--Select--

6. Are you taking any other prescribed medication?

--Select--

What is the medication?

7. Are you taking any over the counter medicines or herbal products?

--Select--

What is the medicines/products you are taking?

8. Have you had your blood pressure checked within the last three months?* (Not required for POP pills)

--Select--

Please provide you blood pressure reading if known (We will need to check this) (Not required for POP pills)

9. Are you pregnant, or might you be pregnant?

--Select--

10. Do you have long periods of immobility?* (Not required for POP pills)

--Select--

Cardiovascular health

11. Are you a smoker (including vaping / use of e-cigarettes)? (If no, go to Yes No question 13) (Not required for POP pill)

--Select--

12. If you are a smoker, would you like help giving up? (Not required for POP pill)

--Select--

13. What is your weight? (We will need to check this) (Not required for POP pill)

14. What is your height? (We will need to check this) (Not required for POP pill)

15. Do you have a current or past history of ischaemic heart disease, vascular disease, stroke, or transient ischaemic attack (TIA)?

--Select--

16. Do you have diabetes?* (If no, go to question 18) (Not required for POP pill)

--Select--

17. If yes, has this affected any of your organs (causing retinopathy, nephropathy, or neuropathy)? (Not required for POP pills)

--Select--

18. Have you ever had a deep vein thrombosis or pulmonary embolus? (Not required for POP pills)

--Select--

19. Do you have a current or past history of any heart disease? (Not required for POP pills)

--Select--

20. Do you have parents, siblings or children who have had heart disease or strokes under the age of 45? (Not required for POP pills)

--Select--

21. Do you have parents or siblings that have had a deep vein thrombosis or Yes No pulmonary embolus under the age of 45? (Not required for POP pills)

--Select--

22. Do you have any blood clotting illnesses / abnormalities? (Not required for POP pills)

--Select--

23. Do you have any problems with your heart muscle or any impaired heart function? (Not required for POP pills)

--Select--

24. Do you have or have you been diagnosed with atrial fibrillation? (Not required for POP pills)

--Select--

Neurological health

25. Do you suffer from migraines? (If no, go to question 28) (Not required for POP pills)

--Select--

26. If so, do you experience visual symptoms or changes in sensation or muscle power on one side of your body? (Not required for POP pills)

--Select--

27. If you suffer from migraines, did your first attack occur when you started taking your contraceptive pill? (Not required for POP pills)

--Select--

Cancers

28. Do you have any past or current history of breast cancer?

--Select--

29. Do you have any undiagnosed breast symptoms? (Not required for POP pills)

--Select--

30. Do you have any family history of breast cancer under the age of 50? (Not required for POP pills)

--Select--

31. Do you have any past or current history of any other cancer?

--Select--

Gastro-intestinal health

32. Do you have any form of liver disease or liver impairment?

--Select--

33. Do you have gall bladder disease that causes you symptoms or is medically managed? (Not required for POP pill)

--Select--

34. Do you suffer from acute/active inflammatory bowel disease or Crohn’s disease?

--Select--

35. Have you had any bariatric surgery or any other surgery that has reduced your ability to absorb things from your stomach?

--Select--

36. Do you suffer from Cholestasis, a condition caused by blocked or reduce flow of bile fluid? (Not required for POP pills)

--Select--

Other health conditions

37. Do you have any planned major surgeries? (Not required for POP pills)

--Select--

38. Have you ever been diagnosed with Anti phospholipid syndrome (APS) (also known as Hughes syndrome) with or without Lupus? (Not required for POP pills)

--Select--

39. Have you ever had an organ transplant that has resulted in complications? (Not required for POP pills)

--Select--

40. Do you have severe kidney impairment or acute renal failure? (Not required for POP pill)

--Select--

41. Have you been diagnosed with Acute porphyria? (applies to POP only)

--Select--

When submitted this form will be sent to out pharmacist who will review your information as soon as possible and update you

Send

Contraceptive Advice Links & Guidance

Combined pill

https://www.axess.clinic/information/contraception/combined-pill/