Contraceptive Pill Checklist

In order to provide the contraceptive pill safely we need to ask you a number of questions.

We would be grateful if you could complete this form when you are due your annual review, or when requested by KAMP.

If you would like more information on Long-Acting Reversible Contraceptive, please view our Long-Acting Reversible Contraceptive (LARC) page.

Contraceptive Pill Checklist

Contraceptive Pill Checklist

Patient Details

Please measure your blood pressure:

For a list of validated home blood pressure monitors, visit or discuss with your pharmacy.

Are your happy with your contraception? *
Do you have any queries about your contraception? *
Are you aware of the alternatives such as long acting reversible contraceptive?
Would you like to book a consultation with a doctor to discuss or arrange fitting a long acting reversible contraceptive?
Smoking Status: *
Would you like help giving up smoking?
Please state whether weight is in st/Ibs or KG.
Please state whether height is in ft/inches or cm.
Is your weight stable? *
Any recent loss or gain in weight? *
Month and year if exact dates are not known.
Was there anything unusual with your last period?
Do you experience severe abdominal pain during periods? *
Do you suffer from migraines? *
Do you suffer from visual symptoms or changes in sensation or muscle power on one side of your body? *

With relation to your current pill, are you aware of:

How the pill works? *
What to do if you miss a pill? *
The fact that contraception may not work if you have diarrhoea or vomiting? *
The fact contraceptive pill does not protect you from Sexually Transmitted Infection (STI), so you will need to use a condom as well to protect yourself? *

Your Health and Family History

Do you have diabetes? *
Do you have blood clotting illnesses/ abnormalities? *
Do you have parents or siblings who have had heart disease or stroke under the age of 45? *
Have you or any family member under the age of 45 had a deep vein thrombosis or Pulmonary Embolus (blood clot in the leg or lung)? *
Do you have any family history of breast cancer under the age of 50? *
Have you had a smear test in the last 3 years (if 25-50) or 5 years (if 50-65)? *
If you are over the age of 50 have you had a mammogram in the last 3 years?
Would you like us to send you information about how to check your breasts? *