Q No.QuestionAnswer1Are you taking any type of oral contraception? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No2Are you pregnant or breast feeding or intending to become pregnant or start breast feeding whilst taking this medication? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No3Are you allergic to any contraceptive? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No4Have you or any family member had a blood clot affecting the legs (deep vein thrombosis) or lungs (pulmonary embolism)? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No5Have you been diagnosed with any of the following? • Irregular vaginal bleeding of unknown cause • Diabetes • Depression • Epilepsy, migraine, asthma, kidney or heart problems • Myocardial infarction (heart attack) • High blood pressure • Angina • Any liver disease or disturbance of liver function • Jaundice or herpes during pregnancy • Severe itching • Porphyria (a rare metabolic disorder) • Dubin-Johnson Syndrome (chronic jaundice (yellowing of the skin or eyes)) or Rotor Syndrome (jaundice in childhood) • An inherited disorder of the red blood pigment haemoglobin (porphyria) • Cancer of the breast or genital tract You must answer this question.You must answer this question.Please write your explanation in the box below Yes No6Are you taking any of the following medications? • Medicines to treat epilepsy (e.g. phenytoin, carbamazepine) • Antibiotic medicines to treat an infection (e.g. tetracyclines, rifampicin, co-trimoxazole) • Antiviral medicines to treat HIV (e.g. ritonavir, nelfinavir) • Anticancer medicines • Herbal preparations containing St John’s Wort (Hypericum perforatum) • Aminoglutethimide, sometimes used in Cushing’s syndrome • Ciclosporin (for suppressing the immune system) • Non-steroidal inflammatory drugs (NSAIDs) for treating pain and inflammation • Medicines for high blood pressure • Rifamycin • Warfarin • Sex hormones • A statin for high cholesterol • Griseofulvin You must answer this question.You must answer this question.Please write your explanation in the box below Yes No7Do you agree to the following? • You will seek medical attention if you experience any unusual side effects • The treatment is solely for your own use • You will read the patient information leaflet supplied with your medication You must answer this question.You must answer this question.Please write your explanation in the box below Yes No8What is the name of your GP surgery and do you consent to us contacting them about your treatment? You must answer this question.You must answer this question.Please write your explanation in the box below Gender * Male Female Other First Name * Last Name * Date of birth * Contact Number * Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * Check to add patient. Patient Gender * Male Female Other Patient First Name * Patient Last Name * Patient Date of birth * Patient Contact Number * Patient Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * I confirm that I am over 18 and I agree to the Terms and Conditions.Term and Conditions required!Please fill all required fields
