Pill check form Consent for storing submitted data Consent for storing submitted data Full Name Date of Birth Address Country Contact Number Email Blood pressure reading Height Weight Do you smoke? Yes No Do you have/have you had breast cancer? Yes No Do you have vascular disease? Yes No Do you have a history of clots (DVT or PE) or clotting problems? Yes No Do you have migraine with aura? Yes No Are you concerned about any of this information or want to discuss this further with a clinician? Yes No Are you suffering from any side effects? Yes No Did you know that if you're sick or have diarrhoea you should treat this like a missed pill? Yes No On a scale of 1-10 how confident do you feel about what to do if you miss a pill? Are you due a cervical smear? Yes No I don't know Do you check your breasts every month and do you feel confident to do so? Yes No Are you currently prescribed a GLP-1 medication, these can be prescribed for type two diabetes, or to facilitate weight loss (Tirzepatide, Semaglutide, Exenatide, Liraglutide, Dulaglutide, or Lixisenatide) ? Yes No If yes, please specify brand and read the information leaflet below At this stage do you have any unanswered questions or concerns? Information leaflet for patients prescribed a GLP-1 medication