Contraception

07/04/2023 04/04/2024

To ensure you are provided with the most effective treatment by our healthcare professional 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 8501944 or email us at [email protected]

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

Yes No

3. Are you female and over 18 years old?

Yes No

4. Please tell us your height and your current weight

Imperial Metric

Enter your height

Foot

Inches

Enter your weight

Enter your height

Cms

Enter your weight

KGs

Your BMI is: 0

5. Would you like information on weight management?

Yes No

6. Do you smoke?

Yes No

6b. Would you like information on stopping smoking?

Yes No

7. Do you drink alcohol?

Yes No

7b. Would you like information on safe alcohol use?

Yes No

8. Are you pregnant, breastfeeding, trying to become pregnant or given birth in the last six weeks?

Yes No

8b. Please provide more information, Did you have a c-section, pre-eclampsia during or after your pregnancy, a blood transfusion or significant loss of blood during or after your delivery?

9. Are you currently taking the pill or any other form of contraception?

Yes No

9b. Please tell us what contraception you are currently using? Are you experiencing any problems with your current pill? How long have you been using this contraceptive pill? Have you had a contraceptive pill check with your doctor or nurse in the last 12 months?

10. Have you used a contraceptive pill before?

Yes No

10b. Please tell us the name of the contraceptive used before and why did you stop using it?

11. What is your blood pressure?

Above 140/80

Below 140/90

12. Have you had a cervical cancer screening test in the last 3-5 years?

Cervical cancer screening tests are recommended for all women aged between 25-64 years.

If you are NOT up-to-date with cervical cancer screening you should see your doctor or contraception nurse. We cannot supply you with the pill.

Yes No

12b. Cervical cancer screening tests are recommended for all women aged between 25-64 years.

13. Have you or your immediate family ever been diagnosed with any of the following health problems?

Blood clot in a blood vessel of your legs (deep vein thrombosis, DVT), your lungs (pulmonary embolus, PE) or other organs.
Diabetes
Migraine
Heart attack, stroke, angina, chest pain, or a transient ischaemic attack (mini-stoke), abnormal heart rhythm, impaired heart function
High blood pressure
High cholesterol or triglycerides
Breast, cervical, liver or other cancer
Liver or gallbladder disease
Epilepsy
Systemic lupus erythematosus (SLE)
Sickle cell disease or any other disorders of the blood
Inflammatory bowel disease such as Crohn’s or ulcerative colitis

Yes No

13b. Please provide more details:

14. Do you take any of the following medications?

HIV Protease Inhibitors (Atazanavir, darunavir, fosamprenavir, lopinavir, ritonavir, saquinavir, tipranavir)
Antifungals (Itraconazole, Ketoconazole, Isavucanazole, posacanzole or Voriconazole)
Antibiotics (Ampicillin, tetracycline)
Antiepileptics (Carbemazepine, Fosphenytoin, Phenobarbitol, Phenytoin, Primidone, Topiramate)
Herbal medication (St Johns Wort)
Netupitant, Nicorandil,Imatinib, Idelalisib, Enazlutamide, Crizotinib, Cobistat, Arpitant, Aprepitant, Dronaderone, Nilotinib, Rifampicin, Riociguat, Lumacaftor, Ciclosporin, Modafanil.

Yes No

14b. Please provide more details:

15. Have you had any surgery in the last 12 months, or are you immobile?

Yes No

16. Do you have unexpected or unusual vaginal bleeding e.g bleeding between periods, after sex, very heavy or painful periods?

Yes No

16b. Have you discussed this with your doctor? What did the doctor advise was causing the bleeding? What tests or examinations did you have? Has the bleeding changed since you last spoke to your doctor (has it got worse, reduced or stopped)?

17. Do you feel vulnerable or are you being forced to obtain treatment?

You are not alone, we can help you. Contact us at [email protected] or call us at 0115 8501944.

Yes No

18. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

Yes No

18b. Please provide more details:

19. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

Yes No

19b. Please provide more details:

20. Are you allergic to any medicines or other substances e.g. peanuts or soya?

Yes No

20b. Please provide more details:

21. We will need to inform your GP of the contraceptive supply. Please provide your GP details?

22. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] so we can talk through your options.

You understand that being sick (vomiting) or have diarrhoa can affect the absorption of the pill and how well it works.
You understand the risks and possible side effects of taking contraception and that you will report to your doctor immediately if you experience any pain in the leg, difficulty breathing or new onset of migraines.
You have read the information available on the treatments and medication web page and understand the side effects, their 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 that 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 No

23. 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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