Pill Check Questionnaire

Please note, this questionnaire does not provide medical advice, and if you have any concerns regarding your health, please book in for an appointment through our usual channels.

Do you consent to the following information being used to guide your medical care?

Do you suffer with any of the following conditions?

If you have selected one or more above options, please include details regarding this (including when this was diagnosed, and how it is being managed):

Any other significant health conditions?

Do you have a family history of any of the following conditions?

If you have selected one or more above options, please include details regarding this:

Do you remember to take your pill regularly?

Are you familiar with what to do if you miss your pill, have vomiting or diarrhoea, or require surgery?

Have you had any side effects from the pill? (If so, please include details)

Do you smoke? (If you do, how many?)

Do you drink alcohol? (If so how many units per week?)

Would you be interesting in suing a longer acting contraception method e.g. Implant, Depot Injection, Copper or Hormonal Coil, which would mean you would not have to take a pill every day?

Do you know your current weight? (If so, please include details)

Do you know your current height? (If so, please include details)

Do you have a recent blood pressure (within the last 2 weeks)? (If so please include readings)

If you do not have access to a blood pressure or weighing machine, please note these are available to do at our practice - just ask the reception team. If done at home you can then drop these readings off at surgery or if unable to do at home you can arrange an appointment to have these done. Please note if we do not have a recent weight and blood pressure your pill check will not be complete.

Thank you.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to The Medlock Medical Practice • Keppel Building, Failsworth Health Centre, Ashton Road West, Failsworth Manchester, M35 0AD.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.