{"id":1116,"date":"2026-08-21T17:19:14","date_gmt":"2026-08-21T16:19:14","guid":{"rendered":"https:\/\/surgeryweb-scot.org.uk\/n31916\/?page_id=1116"},"modified":"2026-08-21T17:19:14","modified_gmt":"2026-08-21T16:19:14","slug":"contraceptive-pill-review","status":"publish","type":"page","link":"https:\/\/surgeryweb-scot.org.uk\/n31916\/contraceptive-pill-review\/","title":{"rendered":"Contraceptive Pill Review"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_20' style='display:none'><div id='gf_20' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_20' id='gform_20'  action='\/n31916\/wp-json\/wp\/v2\/pages\/1116#gf_20' data-formid='20' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_20' class='gform_fields top_label form_sublabel_above description_above validation_above'><div id=\"field_20_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_1'><span class='gform-field-label__text'>Full Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_20_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_20_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_20_3' class='ginput_container ginput_complex gform-grid-row'>\n                                    <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_20_3_2_container'>\n                                        <label for='input_20_3_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <input type='number' maxlength='2' name='input_3[]' id='input_20_3_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                    <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_20_3_1_container'>\n                                    <label for='input_20_3_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                    <input type='number' maxlength='2' name='input_3[]' id='input_20_3_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                               <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_20_3_3_container'>\n                                        <label for='input_20_3_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                        <input type='number' maxlength='4' name='input_3[]' id='input_20_3_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                   <\/div>\n                                <\/div><\/fieldset><fieldset id=\"field_20_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-formatted gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_phone'>\n\t\t\t<div class=\"gform-phone\" role=\"application\">\n\t\t\t\t<div class=\"gform-phone__input-wrapper\">\n\t\t\t\t\t<span class=\"ginput_country-selector_container\">\n\t\t\t\t\t\t<label for='country_selector_button_4' id='country_selector_button_4_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n\t\t\t\t\t\t<button type=\"button\" id=\"country_selector_button_4\" class=\"gform-phone__country-selector gform-theme-button gform-theme-button--tertiary\" aria-haspopup=\"listbox\" aria-expanded=\"false\" aria-controls=\"gform_phone_dropdown_6a8a03a52a843\" aria-label=\"Select country\" >\n\t\t\t\t\t\t\t<span class=\"gform-phone__flag-icon gform-phone__flag-icon--gb\"><\/span>\n\t\t\t\t\t\t\t<span class=\"gform-phone__dial-code\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<span class=\"ginput_phone_container\">\n\t\t\t\t\t\t<label for='input_20_4_visible' id='input_20_4_visible_label' class='gform-field-label gform-field-label--type-sub '>Phone Number<\/label>\n\t\t\t\t\t\t<input type=\"tel\" class=\"gform-phone__input\" id=\"input_20_4_visible\" name=\"\" autocomplete=\"tel\" value=\"\"   aria-required=\"true\" aria-invalid=\"false\"  >\n\t\t\t\t\t\t\n\t\t\t\t\t<\/span>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"gform-phone__dropdown gform-phone__dropdown--hidden\" role=\"listbox\" id=\"gform_phone_dropdown_6a8a03a52a843\" tabindex=\"-1\">\n\t\t\t\t\t<div class=\"gform-phone__search-wrapper\">\n\t\t\t\t\t\t<input type=\"text\" class=\"gform-phone__search\" placeholder=\"Search countries\" aria-label=\"Search for a country\" aria-controls=\"gform_phone_dropdown_6a8a03a52a843_list\">\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<ul class=\"gform-phone__country-list gform-ul-reset\" id=\"gform_phone_dropdown_6a8a03a52a843_list\" role=\"listbox\" aria-label=\"Country list\">\n\t\t\t\t\t\t<!-- Country items will be populated by JavaScript -->\n\t\t\t\t\t<\/ul>\n\t\t\t\t\t<div class=\"gform-phone__aria-live-search-status\" aria-live=\"polite\" aria-atomic=\"true\" style=\"position: absolute; width: 1px; height: 1px; margin: -1px; border: 0; padding: 0; overflow: hidden; clip: rect(0, 0, 0, 0); clip-path: inset(50%); white-space: nowrap;\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"gform-phone__aria-live\" aria-live=\"polite\" aria-atomic=\"true\" style=\"position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0 0 0 0); clip-path: inset(50%); border: 0; white-space: nowrap;\"><\/div>\n\t\t\t<\/div><input name='input_4' id='input_20_4' type='hidden' value='' class='large' data-phone-format='formatted' data-default-country='gb' data-show-country-code='false' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/fieldset><div id=\"field_20_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_5'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_20_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_20_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_6'><span class='gform-field-label__text'>Name of contraceptive pill currently taking<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_20_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_20_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you having any problems with your contraception that you would like to discuss?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_7'>\n\t\t\t<div class='gchoice gchoice_20_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes'  id='choice_20_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_7_0' id='label_20_7_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No'  id='choice_20_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_7_1' id='label_20_7_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_8\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><p><strong>Please contact the practice to arrange an appointment to speak with a clinician.<\/strong><\/p><\/div><fieldset id=\"field_20_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Has your bleeding pattern changed since your last review or are you having any irregular bleeding e.g. between periods or after intercourse?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_9'>\n\t\t\t<div class='gchoice gchoice_20_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_20_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_9_0' id='label_20_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_20_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_9_1' id='label_20_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_20_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you experienced any new headaches since your last review?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_10'>\n\t\t\t<div class='gchoice gchoice_20_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Yes'  id='choice_20_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_10_0' id='label_20_10_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='No'  id='choice_20_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_10_1' id='label_20_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_20_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you forgotten to take your pill on more than one occasion per month?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_11'>\n\t\t\t<div class='gchoice gchoice_20_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_20_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_11_0' id='label_20_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_20_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_11_1' id='label_20_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_20_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you know what to do in the event of a missed pill?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_12'>\n\t\t\t<div class='gchoice gchoice_20_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Yes'  id='choice_20_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_12_0' id='label_20_12_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='No'  id='choice_20_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_12_1' id='label_20_12_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_20_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you interested in long acting reversible contraception e.g. coil\/implant and would like to discuss this with a clinician?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_13'>\n\t\t\t<div class='gchoice gchoice_20_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes'  id='choice_20_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_13_0' id='label_20_13_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_20_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_13_1' id='label_20_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_20_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you currently receiving weight reducing injections from a private clinic (e.g. Mounjaro, Wegovy)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_15'>\n\t\t\t<div class='gchoice gchoice_20_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_20_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_15_0' id='label_20_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_20_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_15_1' id='label_20_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_16'><span class='gform-field-label__text'>Please provide the details of the injection you are taking - name, dose and date commenced - as this could affect your contraception.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_20_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_20_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Have you been diagnosed with or experienced any of the following conditions:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_17'><div class='gchoice gchoice_20_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Migraines (with or without aura) and\/or new headaches'  id='choice_20_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_1' id='label_20_17_1' class='gform-field-label gform-field-label--type-inline'>Migraines (with or without aura) and\/or new headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Deep vein thrombosis (a blood clot in the veins of the leg)'  id='choice_20_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_2' id='label_20_17_2' class='gform-field-label gform-field-label--type-inline'>Deep vein thrombosis (a blood clot in the veins of the leg)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Pulmonary embolism (a blood clot in the lungs)'  id='choice_20_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_3' id='label_20_17_3' class='gform-field-label gform-field-label--type-inline'>Pulmonary embolism (a blood clot in the lungs)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='Breast Cancer'  id='choice_20_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_4' id='label_20_17_4' class='gform-field-label gform-field-label--type-inline'>Breast Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='Stroke\/TIA\/heart attack'  id='choice_20_17_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_5' id='label_20_17_5' class='gform-field-label gform-field-label--type-inline'>Stroke\/TIA\/heart attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_17_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.6' type='checkbox'  value='Gynaecological cancers'  id='choice_20_17_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_6' id='label_20_17_6' class='gform-field-label gform-field-label--type-inline'>Gynaecological cancers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_17_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.7' type='checkbox'  value='High blood pressure'  id='choice_20_17_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_7' id='label_20_17_7' class='gform-field-label gform-field-label--type-inline'>High blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_17_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.8' type='checkbox'  value='Diabetes'  id='choice_20_17_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_8' id='label_20_17_8' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_17_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.9' type='checkbox'  value='Epilepsy'  id='choice_20_17_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_9' id='label_20_17_9' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_17_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.11' type='checkbox'  value='Gallbladder or liver disease'  id='choice_20_17_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_11' id='label_20_17_11' class='gform-field-label gform-field-label--type-inline'>Gallbladder or liver disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_17_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.12' type='checkbox'  value='None of the above'  id='choice_20_17_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_12' id='label_20_17_12' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_20_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Have any of your immediate family (parents or siblings) been diagnosed with any of the following conditions<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_18'><div class='gchoice gchoice_20_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Deep vein thrombosis (a blood clot in the veins of the leg)'  id='choice_20_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_18_1' id='label_20_18_1' class='gform-field-label gform-field-label--type-inline'>Deep vein thrombosis (a blood clot in the veins of the leg)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Pulmonary embolism (a blood clot in the lungs)'  id='choice_20_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_18_2' id='label_20_18_2' class='gform-field-label gform-field-label--type-inline'>Pulmonary embolism (a blood clot in the lungs)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Gynaecological cancers'  id='choice_20_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_18_3' id='label_20_18_3' class='gform-field-label gform-field-label--type-inline'>Gynaecological cancers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Stroke\/TIA\/heart attack'  id='choice_20_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_18_4' id='label_20_18_4' class='gform-field-label gform-field-label--type-inline'>Stroke\/TIA\/heart attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_18_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.5' type='checkbox'  value='Breast Cancer'  id='choice_20_18_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_18_5' id='label_20_18_5' class='gform-field-label gform-field-label--type-inline'>Breast Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_20_18_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.6' type='checkbox'  value='None of the above'  id='choice_20_18_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_18_6' id='label_20_18_6' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_19\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3>Missed Pill Advice<\/h3>\n<p>If you are unsure what do to if you miss one of your pills, or you would just like a reminder of the advice, please following the link below the NHS Inform website.<\/p>\n<p><a href=\"https:\/\/www.nhsinform.scot\/healthy-living\/contraception\/\" target=\"_blank\">Contraception | NHS inform<\/a><\/p>\n<p>Select either 'Combined Pill' or 'Progestogen Only Pill' depending on your current pill and you will find information about what to do if you miss a pill and the actions which should be taken.<\/p><\/div><div id=\"field_20_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_20'><span class='gform-field-label__text'>Weight (kg)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_20_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_21'><span class='gform-field-label__text'>Height (cm)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_20_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_22'><span class='gform-field-label__text'>Blood pressure (mmHg) from a home monitor or via a local pharmacy that offers BP check<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_20_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_20_23\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Please note - We will be unable to complete your prescription request\/review if an up to date blood pressure reading is not submitted. If you are unable to get your BP measured yourself, please arrange an appointment at the practice for this to be done.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_23.1' id='input_20_23_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_20_23_1' ><span class='gform-field-label__text'>I understand<\/span><\/label><input type='hidden' name='input_23.2' value='I understand' class='gform_hidden' \/><input type='hidden' name='input_23.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_20_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Smoking Status<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_24'>\n\t\t\t<div class='gchoice gchoice_20_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Never smoked'  id='choice_20_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_24_0' id='label_20_24_0' class='gform-field-label gform-field-label--type-inline'>Never smoked<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Ex-smoker'  id='choice_20_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_24_1' id='label_20_24_1' class='gform-field-label gform-field-label--type-inline'>Ex-smoker<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_24_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Current smoker'  id='choice_20_24_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_24_2' id='label_20_24_2' class='gform-field-label gform-field-label--type-inline'>Current smoker<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_20_25\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date Stopped<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_20_25' class='ginput_container ginput_complex gform-grid-row'>\n                                    <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_20_25_2_container'>\n                                        <label for='input_20_25_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <input type='number' maxlength='2' name='input_25[]' id='input_20_25_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                    <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_20_25_1_container'>\n                                    <label for='input_20_25_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                    <input type='number' maxlength='2' name='input_25[]' id='input_20_25_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                               <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_20_25_3_container'>\n                                        <label for='input_20_25_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                        <input type='number' maxlength='4' name='input_25[]' id='input_20_25_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                   <\/div>\n                                <\/div><\/fieldset><div id=\"field_20_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_26'><span class='gform-field-label__text'>Please advise how many cigarettes per day you smoke<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_20_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_20_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Alcohol intake - do you drink alcohol?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_27'>\n\t\t\t<div class='gchoice gchoice_20_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Yes'  id='choice_20_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_27_0' id='label_20_27_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_20_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_27_1' id='label_20_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_28'><span class='gform-field-label__text'>How many units per week on average do you drink? 1 unit = half a pint of beer, a small glass of wine or one 25ml measure of spirit.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_20_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_29\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3>WHAT HAPPENS NEXT?<\/h3>\n<p>Once returned to the practice, a clinician will review your answers and issue your prescription as appropriate. <\/p>\n<p>If there are any queries or we have reason to speak with you before your prescription can be issued, you will be contacted to arrange an appointment. <\/p>\n<p>If there are no queries and we do not need to speak with you, your prescription will be issued for a year's supply* and sent to your preferred pharmacy. Please allow 7 working days before collection. <\/p>\n<p>We will ask you to complete this review yearly, prior to your prescription being reauthorised, to ensure that it remains appropriate for you to continue taking.<\/p><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_20' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> <input type='hidden' name='gform_ajax' value='form_id=20&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=081ef0fc4177cead615df1b85b7b4e95' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_20' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_20' id='gform_theme_20' value='gravity-theme' \/>\n            <input type='hidden' 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