| 1 | Are you taking any type of oral contraception?
You must answer this question. You must answer this question. | |
| 2 | Are 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. | |
| 3 | Are you allergic to any contraceptive?
You must answer this question. You must answer this question. | |
| 4 | Have 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. | |
| 5 | Have 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. | |
| 6 | Are 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. | |
| 7 | Do 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. | |
| 8 | What 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. | |
