Will you be 35 years or older within the next 12 months?
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BMI. If you are unsure what your BMI is, use the official NHS BMI calculator found online at:- https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/
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Blood pressure entry (Both Systolic and Diastolic figures - eg 120/80)
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Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months?
Have you been diagnosed with or experienced any of the following conditions in the past 12 months?
Are you currently taking any of the following medications?
Do you suffer from migraines affecting your vision, or a headache associated with weakness or numbness on one side of your face or body, or difficulty with speech? *
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Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? *
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Have you forgotten to take your pill on more than one occasion per month?
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Would you like to discuss 'what to do in the event of a missed pill' with you GP or practice nurse?
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Would you like to discuss long acting reversible contraception options with you GP or practice nurse? (I.e an implant, coil or depo provera injection)
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Which contraception do you require? (i.e Desogestrel, Microgynon, Cerelle, etc.)
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Are you experiencing any side effects from your contraceptive medication?
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If so, please include details of the side effects below.
When was your last smear?
Have you ever had an abnormal smear result?
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Are you or is there any chance you might be pregnant?
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Have you given birth in the last 12 weeks?
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Is there anything that you would like to tell us that we have not asked?
THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.
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