Bacterial Vaginosis Assessment

06/11/2025

To ensure you are provided with the safest and most effective treatment by our healthcare professionals please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 850 1944 or email us at enquiries@thefamilychemist.co.uk

About You

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

Only the patient should be filling in the consultation.

Do not order medication for another patient or order multiple medications for different patients on a SINGLE order. Please register separate accounts for each patient as each account is treated as a medical record.

Yes No

3. Are you aged 18-60?

We cannot provide treatment to those under 18 or over 60 years of age. Please contact your GP for support.

Yes No

4. Are you breastfeeding, pregnant or planning to become pregnant?

Yes No

4b. Please tell us whether you are breastfeeding or pregnant (and how many weeks)?

5. Please confirm why you wish to have bacterial vaginosis (BV) treatment?

Positive home test for BV

Diagnosed by GP or sexual health clinic

Had BV before and recognise the symptoms

None of the above

6. Do you have any of the following symptoms?

It is unlikely that you have BV. Please contact your GP/sexual health clinic for review.

Thin, white or watery/grey vaginal discharge
Discharge that has a fish-like odour

Yes No

7. Do you have any of these symptoms?

Your symptoms may be caused by an infection other than BV. Please contact your GP or sexual health clinic for review.

Frothy, yellow or green discharge
Soreness
Itching, sores, blisters or ulcers in the vaginal area
Irregular or unexplained vaginal bleeding

Yes No

8. Have you experienced fever, shivers, lower abdominal pain or previous pelvic inflammatory disease?

We recommend you contacting your GP or sexual health clinic urgently for review of your symptoms.

Yes No

9. In the last 12 months, have you been treated for BV?

Yes No

9b. Please specify how many treatment courses you have had?

3 or less

More than 3

10. If you have had BV treatments in the past 12 months, can you confirm if you have also had a test for Sexually Transmitted Infections (STI)?

We recommend that women with symptoms of BV have an STI test to check for other potential infections.

Yes - negative results

Yes - received treatment

Yes - no treatment received

No - not tested

11. Do you have, or have you ever had, any of the following conditions?

Acute Porphyria
Liver disease
Kidney disease
Inflammatory bowel disease
Antibiotic induced colitis

Yes No

11b. Please provide more details:

12. Are you currently taking, or recently stopped taking any medicines (including over-the-counter medicines, herbal medicines or recreational drugs) - including any of the ones listed below?

Antibiotics
Anticoagulants (blood-thinners) like warfarin or acenocumarol
Amiodarone
Busulfan
Capecitabine
Ciclosporin
Disulfiram
Fluorouracil
Lithium
Phenobarbital
Phenytoin
Primidone

Yes No

12b. Please provide more detail:

13. Have you recently (in the past 6 weeks) given birth, had a miscarriage or termination of pregnancy?

We are unable to provide treatment. Please contact your GP for advice and support.

Yes No

14. In the recent months (2 months or less), have you had any gynaecological procedures or coil insertion/removal?

We are unable to provide treatment. Please contact your GP for advice and support.

Yes No

15. Do you have any other medical condition(s) or past surgical procedures?

Yes No

15b. Please provide more details:

16. Do you have any allergies to medicines or substances (e.g. peanuts, soya etc.) or to metonidazole or clindamycin?

Yes No

16b. Please provide more details:

17. Do you drink alcohol?

Do not drink alcohol while taking metronidazole and for 48hours after finishing treatment.

Yes No

18. Would you like us to pass on details of your treatment to your GP?

Yes No

18b. Please provide your GP's details:

Please Provide GP Email (preferred):

Unable to find your surgery? Click Here

19. Do you give consent for our clinical team to check your NHS Summary Care Records if required?

Yes

20. Please confirm you have read and understood the following statements:

We cannot proceed with your order. You may review the statements above and confirm understanding before changing your answer.

I understand that:

I should finish the full prescribed course of antibiotics.
I should contact my GP if my symptoms don’t improve after treatment, or if they worsen/new symptoms are developed during treatment.
I should seek urgent medical attention if I develop fever, shivers or rigors during treatment.
Intravaginal clindamycin may make condoms and diaphragms less effective, during and for 72hrs after treatment, and I should use additional contraceptive methods where possible.
I should stop using intravaginal clindamycin if I develop diarrhoea.
I should not drink alcohol during and for at least 48hrs after finishing metronidazole treatment.
I should avoid vaginal douching or perfumed products.
I should contact my GP if I have more than 3 episodes of BV despite having treatment.

Yes No

21. Do you agree with the following?

You have read the information available on the treatments and medication web page and understand the side effects, effectiveness and alternatives available.
You have answered the questions honestly and accurately and the treatment is solely for your personal use.
You will read and understand the patient information leaflet supplied with your medication.
You understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

Yes

22. I confirm that I have read the information in this questionnaire and will follow the advice from the patient information leaflet before using the provided treatments.

Yes

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Bacterial Vaginosis Assessment

About You

Your Medical History

0115 850 1944

enquiries@thefamilychemist.co.uk

13 Poplars Court,
Nottingham,
NG7 2RR

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About You

Your Medical History

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