Contraceptive Pill Questionnaire

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Personal Details

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Are you currently taking the oral contraceptive pill, prescribed by a GP in the UK?: *

Is there any chance you could be pregnant, or have you had unprotected sex in the last 4 weeks (e.g. not using condoms when you have missed a pill)?: *

Was your blood pressure below 140/90 within the last 6 months?: *

Smoking Status : *

Does any of the following apply to you?: *

If you are not sure if you are taking a combined oral contraceptive (COC) pill or a progesterone only pill, please check your packet and then tick one of the boxes below.

The COC pill contains two ingredients, oestrogen and progesterone. Common brands include Microgynon, Rigevidon, Marvelon, Mercilon, Cilest, Ovranette, Yasmin, Femodene, Loestrin, Brevinor, Norimin.

Most COCs are taken for 3 weeks out of 4, with a 1 week gap. You will have been advised that you do not need to use another method of contraception as long as you have not missed a pill by more than 1 day.

The progesterone only pill is taken at the same time every day, without a week off. Common brands include Cerazette, Micronor, Norgeston, Noriday, Cerelle.

You will have been advised that you need to use another method of contraception if you miss a pill by more than 3 hours (or more than 12 hours if you are taking a desogesterol pill).

Are you currently taking:: *

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This form collects personal and medical informanot tion about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Contraceptive Pill Questionnaire

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