Help us prepare for your appointment by completing this form in advance.
A few questions about your health and contraceptive history.
This is optional, but filling it in means your doctor can check any safety considerations in advance and make the most of your consultation time. Takes about 4 minutes.
Approximate is fine
Select all that apply
Age in years
Count from first day of one period to first day of next
DD/MM/YYYY
Aura = visual disturbances, zigzag lines, flashing lights, numbness or tingling BEFORE the headache
Clinical note - this will be reviewed at consultation
Important for contraception safety
Age >35 + smoking = contraindication for combined hormonal contraception
If you haven't checked recently, we can measure at consultation
Clinical note - this will be reviewed at consultation
ABSOLUTE CONTRAINDICATION for combined hormonal contraception
This is important for safe contraception planning
Also mention if anyone has been diagnosed with thrombophilia (clotting disorder)
ABSOLUTE CONTRAINDICATION for combined hormonal contraception
Hormonal contraceptive choice depends on specific cancer details
May affect hormonal contraceptive choice
Some liver conditions affect contraceptive choice
Affects contraceptive choice and monitoring
Enzyme-inducing drugs reduce hormonal contraceptive effectiveness
Used to calculate BMI. BMI >35 may affect some methods
Combined contraception may reduce milk supply if <6 months postpartum
Blood clot risk is elevated in the first 6 weeks after birth
Helps choose the right contraception - reversibility matters
Include miscarriages, terminations, live births
Select all that apply
No judgment - helps assess STI risk and contraceptive needs
Contraception ≠ STI protection. Condoms protect against both
We can discuss STI screening at your consultation
Different methods affect bleeding differently
Select all that interest you
Helps us avoid methods that caused you issues before
Select all that matter to you
Select all concerns - we can discuss mitigation
Some medications (especially enzyme-inducing drugs like rifampicin, phenytoin, carbamazepine, St John's Wort) reduce hormonal contraceptive effectiveness
Reduces effectiveness of hormonal contraceptives
Select all that apply
No pressure - this is your space to mention anything relevant
Anything you would like your doctor to know before your appointment.
Your information is sent securely to your doctor at LoveMyLife. We will not share your details with third parties. By submitting this form, you consent to LoveMyLife contacting you regarding your appointment.