NHS Pharmacy Contraception Service – Tier 1 – Ongoing supply of oral contraception

NHS Pharmacy Contraception Service - Tier 1 – Ongoing supply of oral contraception

Pre-consultation Screening for supply of your pill

What is the name of your Pill? *

Which type is your pill *

Progesterone Only (minipill)

Combined (Progesterone and oestrogen) oral contraceptive

First Name *

Last Name *

Date of birth dd/mm/yyyy *

Age *

Post Code *

Email Address *

This is so we can email your results over to you.

Mobile Number *

This is so we can text your results over to you.

GP Surgery * GP Surgery

CONSENT

I consent to the following information sharing that will take place: *

I give consent for the pharmacist to provide me with a supply of my oral contraception

I give consent for my GP to be notified of the supply of oral contraception via the NHS Community Pharmacy Oral Contraception Management Service.

I give consent for my information to be legally shared with NHS England as part of the service monitoring and evaluation and the NHSBSA and NHS England for the purpose of contract management and post-payment verification.

What is the name of your Oral Contraceptive Tablet? *

Medical History

Do you have any allergies? *

Yes

List below *

Are you currently regularly taking any other prescribed, over-the-counter or herbal medicines? *

Yes

Please add any medication you have stopped in the last 4 weeks

Upload a picture of your repeat

Maximum file size: 67.11MB

Alternatively, type list below

Has there been any changes to your medical, surgical or mental health since the last supply of your oral contraceptive? *

Yes

Has there been any relevant past and present medical and sexual history? *

Yes

Are you pregnant, or might you be pregnant? *

Yes

Have you had any problems with or side effects from your contraceptive pill? *

Yes

Have you been diagnosed with Acute porphyria? *

Yes

Do you have a current or past history of ischaemic heart disease, vascular disease, stroke or transient ischaemic attack (first attack only that occurred whilst taking this contraceptive) *

Yes

Do you have a past or current history of breast cancer? *

Yes

Do you have any past or current history of any other cancer? *

Yes

Do you have any form of liver disease or liver impairment? *

Yes

Do you have a current or past history of benign or malignant liver tumour (hepatocellular adenoma or hepatocellular carcinoma)? *

Yes

Do you have a current or past history of severe (decompensated) cirrhosis? *

Yes

Have you had any bariatric surgery or any other surgery that has reduced your ability to absorb things from your stomach? *

Yes

Do you have a family history of medical conditions? *

Yes

If answered yes, please list the medical conditions

Long-acting reversible contraceptives (LARCs) are highly effective form of contraception which are usually inserted intravaginally, into the arm or injected. They last between 13 weeks to 10 years depending on the type of LARC and therefore does not rely on daily pill-taking. Please see this website for further information: Contraception - https://www.sexwise.org.uk/contraception/long-acting-reversible-contraception-larc

Would you be interested in LARCS? (Long Acting Reversible Contraceptives) *

• Yes

• No

Signature *

Clear

First Name *

Last Name *

Date of birth dd/mm/yyyy *

Age *

Post Code *

Email Address *

This is so we can email your results over to you.

Mobile Number *

This is so we can text your results over to you.

GP Surgery * GP Surgery

CONSENT

I consent to the following information sharing that will take place: *

I give consent for the pharmacist to provide me with a supply of my oral contraception

I give consent for my GP to be notified of the supply of oral contraception via the NHS Community Pharmacy Oral Contraception Management Service.

What is the name of your Oral Contraceptive Tablet? *

Your numbers

Weight (kg) *

Kilograms

Height (metres) *

metres

Blood Pressure *

Systolic/DiastolicmmgHG

Recent (within 3 months)

Which arm was measured? *

Left

Right

Medical History

Do you have any allergies? *

Yes

Please list below

Are you currently regularly taking any other prescribed, over-the-counter or herbal medicines? *

Yes

Please add any medication you have stopped in the last 4 weeks

Upload a picture of your repeat

Maximum file size: 67.11MB

Alternatively, type list below

Has there been any changes to your medical, surgical or mental health since the last supply of your oral contraceptive? *

Yes

Has there been any relevant past and present medical and sexual history? *

Yes

Are you pregnant, or might you be pregnant? *

Yes

Have you given birth within the last 6 weeks? *

Yes

Are you currently breastfeeding?

Yes

Do you have risk factors or venous thromboembolism (previous VTE, certain blood conditions/clotting disorders (Antiphospholipid syndrome or factor V Leiden, overweight [BMI of over 30kg/m²], reduced mobility, smoker, dehydration, varicose veins, undergone surgery, suffering significant injury or trauma)? *

Yes

Have you had any problems with or side effects from your contraceptive pill? *

Yes

Are you a smoker or have you stopped smoking less than one year ago? (including vaping / use of e-cigarettes) *

Yes

Do you have significant or prolonged immobility? *

Yes

Do you have a current or past history of any heart disease or have parents, siblings and children who have had heart disease or strokes under the age of 45? *

Yes

Do you have cardiomyopathy with impaired heart function? *

Yes

Do you have or have you been diagnosed with atrial fibrillation? *

Yes

Have you ever had deep vein thrombosis or pulmonary embolism or have parents, siblings and children who have had deep vein thrombosis or pulmonary embolism under the age of 45? *

Yes

Do you have a current or past history of migraine with neurological symptoms at any age (including aura – visual symptoms or changes in sensation or muscle power on one side of your body)? *

Yes

Do you have a past or current history of breast cancer or are known to be a carrier of gene mutations associated with breast cancer? *

Yes

Do you have any past or current history of any other cancer? *

Yes

Do you have any form of liver disease or liver impairment? *

Yes

Do you have a current or past history of benign or malignant liver tumour (hepatocellular adenoma or hepatocellular carcinoma)? *

Yes

Do you have a current or past history of severe (decompensated) cirrhosis? *

Yes

Do you have gall bladder diseases which is currently symptomatic or medically managed? *

Yes

Do you suffer from Cholestasis, a condition caused by blocked or reduce flow of bile fluid? (related to past combined hormonal contraceptive use?) *

Yes

Have you had any bariatric surgery or any other surgery that has reduced your ability to absorb things from your stomach? *

Yes

Do you have any planned major surgeries? *

Yes

Do you have diabetes with end organ disease (retinopathy, nephropathy, neuropathy)? *

Yes

Have you ever been diagnosed with Anti phospholipid syndrome (APS) (also known as Hughes syndrome) with or without Lupus? *

Yes

Have you ever had an organ transplant that has resulted in complications? *

Yes

Do you have severe kidney impairment or acute renal failure? *

Yes

Have you been diagnosed with Acute porphyria? *

Yes

Do you have one or more of the following risk factors for cardiovascular disease (CVD); (such as smoking (including vaping/use of e-cigarettes), diabetes, hypertension, obesity, and dyslipidaemias). *

Yes

Do you have a current or past history of ischaemic heart disease, vascular disease, stroke, or transient ischaemic attack? *

Yes

Do you have a current or past history of venous thromboembolism? *

Yes

Do you have complicated valvular or congenital heart disease, e.g., pulmonary hypertension, history of subacute bacterial endocarditis? *

Yes

Are you known to have thrombogenic mutations, e.g., factor V Leiden, prothrombin mutation, protein S, protein C and antithrombin deficiencies? *

Yes

Do you have a family history of medical conditions? *

Yes

If you answered yes, please list the medical conditions

Would you be interested in LARCS? (Long Acting Reversible Contraceptives) *

• Yes

• No

Signature *

Clear

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NHS Pharmacy Contraception Service – Tier 1 – Ongoing supply of oral contraception

Pre-consultation Screening for supply of your pill

CONSENT

Medical History

CONSENT

Your numbers

Medical History