UMC Pill Check Questionnaire

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Personal Details
Please double check you've entered the correct email address
May be used to identify you
tick one
Yes/No please include pill name or state same as last time
Yes/No include name of medication or supplement
Yes/No include details
A migraine is usually a moderate or severe headache felt as a throbbing pain on one side of the head
An aura is where you have warning signs before your headache begins such as changes to your vision – black spots / wavy lines or numbness/pins and needles
Yes/No/I don't know (please state relative and approximately what age they were diagnosed)
This is important as the oral contraceptive does not protect against sexually transmitted infections
in KGs
in cm
Please include a postcode or address/location

Privacy Consent

This form collects personal and medical informanot tion about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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