Contraceptive Pill Review

Section

Confirmation *

I confirm I have added the most up to date phone number

If you are using a UK mobile number, please use the format 07xxxxxxxxx

Contraception Pill Review

Height (in Metres): *

e.g. 1.75

Weight (in KG): *

e.g. 60.6

BMI:

Would like to be referred for help with weight loss?

Yes

No

Do you regularly check your breasts?

Yes

No

Please ask reception for our information regarding the importance of regular breast self-examination.

Do you suffer from severe headaches or migraines?

Yes - But the Doctor is unaware

Yes - But the Doctor is aware

No

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Are you experiencing any irregular bleeding?

Yes

No

Please book an appointment to see the practice nurse

Blood Pressure

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Sexual Health Screening

We would like to invite you to attend a Sexual Health Screening, just a quick discreet 15 minutes appointment. The screening we provide is for Chlamydia, Syphilis, Gonorrhoea and HIV. By participating to screening, you will be giving us consent to refer you to the ICash Sexual Health Clinic in Norwich if you receive a positive result for Syphilis, rectal Chlamydia, Gonorrhoea or HIV, for appropriate treatment and follow up. Other positive Chlamydia will be treated at the surgery which will include contact tracing. You can choose to receive your results by either text message or letter.

Would you like to attend a Sexual Health Screening?

Yes

No

*

I confirm that the information provided is accurate to the best of my knowledge

Tell us whether you accept cookies