Question 1 of 14
Are you currently pregnant or is there a chance you could be?
Question 2 of 14
Have you been prescribed Birth Control in the past?
Question 3 of 14
Have you given birth, had a termination of pregnancy, or miscarriage in the last 6 weeks?
Question 4 of 14
Do you currently smoke? (This included any form or tobacco/nicotine including e-cigarettes)
(smoking can increase the risk of blood clots with certain types of hormonal contraception)
Question 5 of 14
Do you have high blood pressure? (Normal blood pressure is classed as under 140/90, blood pressure above this range can increase the risk of serious blood clots with certain hormonal birth control)
Question 7 of 14
Have you ever had a deep vein thrombosis (clots in the leg) or Pulmonary Embolism (clots in the lung)? Certain Birth control options can increase the risk of clots with the above
Question 8 of 14
Do you suffer from Migraines with Aura?
Question 9 of 14
Do you have any other medical conditions?
Question 10 of 14
Having you had or are you going to have any major surgeries soon?
Question 11 of 14
Are you currently taking any medications or supplements?
Question 12 of 14
Do you have any Medication Allergies?
Question 6 of 14
Please provide your height and weight below.
Question 13 of 14
Is there any further information you would like to provide?
Question 14 of 14
Would you like to have a video or telephone consultation?