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Abbey Court Surgery

Contraception

For contraceptive requests and reviews. Please complete this form.

Name: *

Date of Birth: *

Address *

Contact Number: *

Contraception: *

New

Review

Date of last menstrual period: *

Do you have regular periods? *

Yes

No

Have you had unprotected sex since your last period? *

Yes

No

What is your preferred method of contraception? Please follow the link below if you are unsure of what contraception method to choose. *

https://patient.info/sexual-health/contraception-methods/

Medical Background

Do you suffer from any of the following conditions?

Migraines: *

Yes

No

Epilespy: *

Yes

No

High Blood Pressure: *

Yes

No

Deep Vein Thrombosis (leg clots/ lung clots) : *

Yes

No

Previous history of ectopic pregnancy? *

Yes

No

Personal history of breast cancer? *

Yes

No

Family History

Family history of blood clot in legs or lung? *

Yes

No

If Yes what relation is this family member to you?

Family history of breast cancer? *

Yes

No

If Yes what relation is this family member to you?

Social History

Smoking Staus: *

Smoker

Non Smoker

Ex Smoker

Please contact reception to make an appointment for a blood pressure and weight check in the treatment room.

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