Progesterone Only Pill (POP) review

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. *

I consent to the practice collecting and storing my data from this form.

What progesterone only pill are you currently taking? *

Cerelle/desorgestrel 75mcg

Noriday/norethisterone 350mcg

Drosperinone 4mg

Do you smoke? *

I smoke cigarettes

I am an ex cigarette smoker

I have never smoked cigarettes

Have you developed any new medical problems in the past 12 months? *

Yes No

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? *

Deep vein thrombosis (a blood clot in the veins of the leg)

Pulmonary embolism (a blood clot in the lungs)

Breast cancer

No

Are you currently taking any medication other than your contraceptive pill? *

Yes No

Are you currently using weight loss injections (for example ozempic, mounjaro, wegovy)? *

Yes No

Have you undergone any surgical procedure (operation) in the past 12 months? *

Yes No

Have you ever undergone weight loss surgery (for example gastric band, gastric sleeve, gastric bypass)? *

Yes No

Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? * *

Yes No

Are you experiencing any unwanted side effects from your contraceptive pill? *

Yes No

Are you aware that there are other methods of contraception available which may be suitable to you – for example the contraceptive implant or an intrauterine device? *

Yes No

Would you like to discuss any of these options with your GP or practice nurse? *

Yes No

I confirm that I am happy to continue with my current contraceptive medication. *

Yes

I am aware that I can seek medical advice at any point should I have any questions regarding this prescription. *

Yes

I agree to inform the GP practice if there is any change to my medical conditions to ensure that this is still suitable for me. *

Yes

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Progesterone Only Pill (POP) review

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