1. Have you read information about contraception on Patient.info?

Yes

No

2. Have you been taking your current pill for a year or more?

Yes

No

3. Please provide the name of your current pill, or a pill you have used in the past that you have tolerated well:

4. What is your Body Mass Index

• Use this BMI (Body Mass Index) calculator and enter your BMI

5. Have you had a smear test in the last 3 years?

Yes

No

6. If you answered Yes to the previous question, do you know the smear result? Please provide:

7. Are you pregnant?

Yes

No

8. Are you breastfeeding?

Yes

No

9. Are you a smoker?

Yes

No

10. Have you ever suffered from a blood clot? (Deep vein thrombosis, Pulmonary embolism)

Yes

No

11. Has anybody in your family suffered from blood clots, breast cancer, or cervical cancer?

Yes

No

12. Do you suffer from any of the following?

13. Are you taking any of the following medications?

14. Have you been advised by your doctor or practice nurse to have special monitoring of the pill?

Yes

No

15. Do you suffer from any serious illnesses?

16. What are your current medical conditions?

17. Do any of the following apply to you?

18. What are your current medications, if any?

19. Do you have any allergies? If so, please list them:

20. Have you considered Long Acting Reversible Contraception?

Yes

No

21. Do you agree to read the leaflet enclosed with your medication?

Yes

No