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Questions Related to Contraception

In order to prescribe treatments for Contraception our doctor needs some information regarding this specific condition. Please complete the following as accurately as possible.


Have you ever used any form of hormonal contraceptive before. (such as the pill, nuvaring, or evra patch)

When was your last face-to-face check up with your regular doctor?

Do you smoke?

Is there a history of Deep Vein Thrombosis or other blood clotting disorders in your family?

Do you suffer from: Migraine, Diabetes, Cancer, Liver Disease?

Are you taking any of the following medications: Carbamazepine, griseofulvin, modafinil, nelfinavir, nevirapine, oxcarbazepine, phenytoin, phenobarbital, primidone, ritonavir, St John's Wort, topiramate, rifabutin or rifampicin?

Do you suffer from acne or hirsutism?

What is your latest blood pressure and when was it done?