Pre-consultation: Contraception

First name *

Last name *

Email *

Phone *

Date of birth *

Are you currently using any form of contraception?

Yes

No

Which contraception method are you currently using?

How long have you been using your current contraception method?

Approximate is fine

How satisfied are you with your current method?

Very satisfied

Mostly satisfied

Not very satisfied

Not satisfied - want to change

If not satisfied, what's the main issue?

Select all that apply

Side effects

Inconvenient/difficult to use

Weight gain

Mood changes

Irregular or heavy bleeding

Reduced libido/sex drive

Partner issues

Want a more effective method

Planning pregnancy soon

Other

At what age did you start your periods?

Age in years

Are your periods regular?

Regular and predictable

Occasionally irregular

Very irregular

No periods currently (amenorrhoea)

What's your average menstrual cycle length?

Count from first day of one period to first day of next

21-25 days

26-30 days (normal)

31-35 days

Over 35 days

Variable - unpredictable

How many days does your period typically last?

1-3 days

4-5 days (normal)

6-7 days

8+ days

How heavy is your menstrual flow?

Light (minimal sanitary products needed)

Moderate (normal use)

Heavy (frequent changes needed)

Very heavy (soaking through, with clots)

Does heavy period flow cause you problems?

Not applicable

No

Yes - affects daily activities

Yes - causes anaemia symptoms

Do you experience period pain (dysmenorrhoea)?

No pain

Mild (manageable)

Moderate (affects activities)

Severe (debilitating, need strong painkillers)

If you have severe period pain, do you need to miss work or school because of it?

Not applicable

No

Occasionally

Regularly

When was your last menstrual period? *

DD/MM/YYYY

Do you experience migraines (severe headaches)? *

Aura = visual disturbances, zigzag lines, flashing lights, numbness or tingling BEFORE the headache

No

Yes, but no aura

Yes, with aura

⚠️ IMPORTANT: Migraine WITH aura is an absolute contraindication for combined hormonal contraception (pill, patch, ring) due to 4x increased stroke risk. If you have migraine with aura, progesterone-only options are safer.

Clinical note - this will be reviewed at consultation

Do you smoke? *

Important for contraception safety

No, never

No, but used to

Yes, occasionally

Yes, regularly

If you smoke regularly, how many cigarettes per day?

Age >35 + smoking = contraindication for combined hormonal contraception

Do you know your blood pressure?

If you haven't checked recently, we can measure at consultation

No, never checked

Yes, normal

Yes, high

If your blood pressure is high, is it treated with medication?

Not applicable

No - untreated

Yes - well controlled

Yes - not well controlled

⚠️ Uncontrolled high blood pressure (>160/100) is an absolute contraindication for combined hormonal contraception.

Clinical note - this will be reviewed at consultation

Have you ever had a blood clot (DVT in leg or PE in lung)? *

ABSOLUTE CONTRAINDICATION for combined hormonal contraception

No

Yes

If yes, tell us more about the blood clot:

This is important for safe contraception planning

Do you have a family history of blood clots?

No

Yes

If yes, who in your family and at what age?

Also mention if anyone has been diagnosed with thrombophilia (clotting disorder)

Have you ever had a stroke or heart attack? *

ABSOLUTE CONTRAINDICATION for combined hormonal contraception

No

Yes

Do you have a personal history of breast cancer?

No

Yes - currently have it

Yes - previously treated

If yes, tell us more:

Hormonal contraceptive choice depends on specific cancer details

Do you have a family history of breast cancer?

May affect hormonal contraceptive choice

No

Yes - mother or sister

Yes - multiple relatives

Do you have any liver disease or liver problems?

No

Yes

If yes, please describe:

Some liver conditions affect contraceptive choice

Do you have diabetes?

No

No, but family history

Yes - Type 1

Yes - Type 2

If you have diabetes, how long and any complications?

Affects contraceptive choice and monitoring

Are you taking any anticonvulsant medications (for epilepsy)?

Enzyme-inducing drugs reduce hormonal contraceptive effectiveness

No

Yes - enzyme-inducing (phenytoin, carbamazepine)

Yes - non-enzyme-inducing (lamotrigine, levetiracetam)

Not sure

Do you have HIV?

No

Yes

If you have HIV, are you on antiretroviral treatment?

Not applicable

No

Yes - well controlled

Yes - not well controlled

What is your height and weight?

Used to calculate BMI. BMI >35 may affect some methods

Are you currently breastfeeding?

No

Yes, exclusively

Yes, mixed feeding

If breastfeeding, how old is your baby?

Combined contraception may reduce milk supply if <6 months postpartum

How long ago did you give birth?

Blood clot risk is elevated in the first 6 weeks after birth

Do you want children (or more children) in the future? *

Helps choose the right contraception - reversibility matters

Yes

Not sure

No

Already have children and am done

If yes, when are you hoping to have children?

Within 1 year

1-3 years

3-5 years

5+ years

How many times have you been pregnant before?

Include miscarriages, terminations, live births

Have you had any pregnancy complications?

No previous pregnancies

No complications

Yes

If yes, which complications?

Select all that apply

Gestational diabetes

Pre-eclampsia/high blood pressure

Blood clot (DVT/PE)

Postpartum depression

Gestational trophoblastic disease

Severe hyperemesis

Other

How many sexual partners have you had in the last 12 months?

No judgment - helps assess STI risk and contraceptive needs

None

One

Two to three

Four or more

Do you consistently use condoms for STI protection?

Contraception ≠ STI protection. Condoms protect against both

N/A - no penetrative sex

Always

Usually

Sometimes

Never

When was your last STI test?

Never tested

Within last 6 months

6-12 months ago

Over 1 year ago

Not sure

Are you concerned about STI risk?

We can discuss STI screening at your consultation

No

Possibly

Yes

What's your preference regarding periods while on contraception?

Different methods affect bleeding differently

Regular monthly bleed

Lighter periods

No periods (amenorrhoea)

No preference - surprise me!

Are there any contraceptive methods you're interested in?

Select all that interest you

Combined pill

Progesterone-only pill (mini-pill)

Implant (rod in arm)

Hormonal coil (IUS/Mirena/Liletta)

Copper coil (IUD)

Patch (weekly)

Vaginal ring

Injection (Depo-Provera)

Condoms

Natural family planning

Not sure - want advice

Have you tried any contraceptive methods before that didn't work for you?

No - first time

Yes

If yes, which methods and what were the problems?

Helps us avoid methods that caused you issues before

What's most important to you in a contraceptive method?

Select all that matter to you

Maximum effectiveness (prevent pregnancy)

Ease of use

Don't have to think about it daily

Non-hormonal

Helps regulate or reduce periods

Helps with acne

Long-acting option

Easily reversible if I change my mind

Low cost

Natural/non-synthetic

Are you concerned about any contraceptive side effects?

Select all concerns - we can discuss mitigation

Weight gain

Mood changes/depression

Acne

Reduced libido/sex drive

Irregular or heavy bleeding

Headaches/migraines

Blood clots (thrombosis)

Not concerned

Don't know

Are you taking any medications? Please list them.

Some medications (especially enzyme-inducing drugs like rifampicin, phenytoin, carbamazepine, St John's Wort) reduce hormonal contraceptive effectiveness

Are you taking St John's Wort (herbal supplement for mood)?

Reduces effectiveness of hormonal contraceptives

No

Yes

What brings you in today? *

Select all that apply

Start new contraception

Switch from current method

Emergency contraception

Review current contraception

Want advice on options

Pre-pregnancy/pre-conception counselling

Concerns about side effects

Other

Is there anything else about your contraception or sexual health we should know?

No pressure - this is your space to mention anything relevant

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Current Contraception

Are you currently using any form of contraception? -

Which contraception method are you currently using? -

How long have you been using your current contraception method? -

How satisfied are you with your current method? -

If not satisfied, what's the main issue? -

Menstrual History

At what age did you start your periods? -

Are your periods regular? -

What's your average menstrual cycle length? -

How many days does your period typically last? -

How heavy is your menstrual flow? -

Does heavy period flow cause you problems? -

Do you experience period pain (dysmenorrhoea)? -

If you have severe period pain, do you need to miss work or school because of it? -

When was your last menstrual period? -

UKMEC Safety Screening (CRITICAL for contraception choice)

Do you experience migraines (severe headaches)? -

⚠️ IMPORTANT: Migraine WITH aura is an absolute contraindication for combined hormonal contraception (pill, patch, ring) due to 4x increased stroke risk. If you have migraine with aura, progesterone-only options are safer. -

Do you smoke? -

If you smoke regularly, how many cigarettes per day? -

Do you know your blood pressure? -

If your blood pressure is high, is it treated with medication? -

⚠️ Uncontrolled high blood pressure (>160/100) is an absolute contraindication for combined hormonal contraception. -

Have you ever had a blood clot (DVT in leg or PE in lung)? -

If yes, tell us more about the blood clot: -

Do you have a family history of blood clots? -

If yes, who in your family and at what age? -

Have you ever had a stroke or heart attack? -

Do you have a personal history of breast cancer? -

If yes, tell us more: -

Do you have a family history of breast cancer? -

Do you have any liver disease or liver problems? -

If yes, please describe: -

Do you have diabetes? -

If you have diabetes, how long and any complications? -

Are you taking any anticonvulsant medications (for epilepsy)? -

Do you have HIV? -

If you have HIV, are you on antiretroviral treatment? -

What is your height and weight? -

Are you currently breastfeeding? -

If breastfeeding, how old is your baby? -

How long ago did you give birth? -

Reproductive Plans

Do you want children (or more children) in the future? -

If yes, when are you hoping to have children? -

How many times have you been pregnant before? -

Have you had any pregnancy complications? -

If yes, which complications? -

Sexual Health

How many sexual partners have you had in the last 12 months? -

Do you consistently use condoms for STI protection? -

When was your last STI test? -

Are you concerned about STI risk? -

Bleeding Preference

What's your preference regarding periods while on contraception? -

Method Preferences & Concerns

Are there any contraceptive methods you're interested in? -

Have you tried any contraceptive methods before that didn't work for you? -

If yes, which methods and what were the problems? -

What's most important to you in a contraceptive method? -

Are you concerned about any contraceptive side effects? -

Current Medications

Are you taking any medications? Please list them. -

Are you taking St John's Wort (herbal supplement for mood)? -

Today's Goals

What brings you in today? -

Is there anything else about your contraception or sexual health we should know? -

Anything else for your doctor?