Contraceptive Pill Request Name First Last Date of Birth Day Month Year What is the name of the pill you are requesting? Have you had any problems whilst on this medication? Yes No Please stateDo you have any new unexpected bleeding since your last review/issue? Yes No Have you been diagnosed with any new health conditions since we last issued you a prescription for the pill? Yes No Please stateHow long have you been taking the pill? Do you or have you suffered from any migraines? Yes No Please describeHave you or any of your immediate family had any of the following? Breast cancer Heart attack Stroke Blood clot (DVT, Pulmonary Embolism) None Have you had your blood pressure checked in the last 6 months? Yes No Please provide new blood pressure reading or come to reception to use the POD. You cannot submit the form without a blood pressure in the last 6 months. Blood Pressure reading from the last 6 months Weight (kg) Height (cm)