Contraception Review What is your name? First Last What is your date of birth? DD slash MM slash YYYY For example, 31/03/1980What is your sex? Male Female Other As recorded on your medical recordWhat is your postcode? Postcode The one used to register with your GPWhat is your phone number?What is your email address? Anyone else with access to your email account may see responses sent to youContraceptive ReviewHeightIn metresWeightIn kilogramsDo you regularly check your breasts? Yes Optional No Optional Do you suffer from severe headaches or migraines? Yes – But the Doctor is unaware Optional Yes – But the Doctor is aware Optional No Optional Are you experiencing any irregular bleeding? Yes Optional No Optional Smoker Status Smoker Optional Ex smoker Optional Never smoked Optional Do you currently vape? Yes Optional No Optional Is there any family history of a clot in the leg or lung? Yes Optional No Optional Are you happy on your current pill? Yes Optional No Optional Blood PressureSystolic “Higher” OptionalDiastolic “Lower” OptionalHeart Rate OptionalConfirmation I confirm that the information provided is accurate to the best of my knowledge