POP Questionnaire PROGESTERONE ONLY PILL (POP) INFORMATION Name First Last Date of Birth DD dash MM dash YYYY PhoneEmail Enter Email Confirm Email Preferred Chemist Progesterone only pill informationFor all contraception choices visit: nhs.uk methods of contraceptionName of current pill Have there been any changes to your bleeding pattern since last review? Yes No Do you have any irregular or unscheduled bleeding? Yes No Do you experience any bleeding after intercourse? Yes No Do you have any unwanted side effects from this medication? Yes No The progesterone only pill should be taken at the same time each day. Have you had any missed or late pills? Yes No Would you like to consider changing your method of contraception? If yes please see link above. Yes No Medical HistoryThe following questions are asked to ensure it is still safe to continue prescribing this medication for you.Do you have any new medical conditions that your GP may not be aware of? Yes No Do you or your family have a medical history of Breast Cancer (current or past) Liver disease Heart disease/angina/heart attack Stroke or mini-stroke None of the above Are you taking any new medications? Yes No Do you take any over the counter or herbal/alternative medications? Yes No Are you overdue your smear test?- If yes please call the surgery to book this in as soon as you can. Yes No SummaryOnce submitted, this form will be reviewed by a clinician. If appropriate, a further prescription will be issued and sent to your requested local pharmacy. The different types of contraception | NHS informI confirm that I am happy to continue using the progesterone only pill as a form of contraception. Yes No I confirm that I am aware of what to do if I miss a pill or am late taking my pill. (See link above for more information if needed). Yes No I am aware that the progesterone only pill does not protect against sexually transmitted infection (STI). Condoms are required in addition to provide protection against STI Yes No I confirm that the information provided is accurate to the best of my knowledge Yes No Data ProtectionThis 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.Consent I consent to the practice collecting and storing my data from this form.