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Morning After Pill Assessment

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]

About You

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

STOP! This consultation should only be filled in by the female patient taking the morning after pill.

3. Are you female and over 18 years old?

STOP! Emergency contraception is not available for men or females under 18.

4. What is your BMI?

Levonelle is less effective for women with a Body Mass Index (BMI) over 26 kg/m2 or women weighing over 70kg. These women should take EllaOne or a Copper IUD. If EllaOne is not suitable then 2 tablets of Levonelle should be ordered. This is an off-label use. Clinicians take responsibility for prescribing. By ordering 2 tablets as a single dose, you consent to off-label use.

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Your BMI is: 0

5. Are you pregnant, breastfeeding or trying to become pregnant?

5b. Are you pregnant or breastfeeding? If you are pregnant how many weeks pregnant are you?

6. Why do you need emergency contraception?

7. What date and time did you have unprotected sex?

  • ellaOne can be used up to 5 days (120 hours) after sexual intercourse, whereas Levonelle, or generic levonorgestrel, can be used up to 3 days (72 hours) after intercourse. The earlier it is taken, the more effective it is.
  •  Next-day delivery is guaranteed on a working day only if the order is placed before 2pm. Bank holidays and weekends are not working days.

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

Regular contraception is more reliable than occasional use of emergency contraception. Coils, implants or injections are the most reliable. Contraceptive pills, patches, vaginal rings, caps or condoms are other reliable contraceptives.

8b. Please provide more details:

9. Since your last period, did you have any other unprotected sex or condom failures?

If you’ve had other unprotected sex within the last 3 weeks, it may be too early to be sure you are not pregnant. The emergency contraceptive pill can still be used, but you need to do a pregnancy test if you do not go on your period within 5-7 days of the expected date.

9b. Did you take the emergency contraception? If yes, what did you take and when?

10. Was your last period normal for you or was it abnormal (i.e. lighter, shorter or later than usual)?

11. Have you already taken an emergency contraception in this cycle (i.e. since your last period)?

Ellaone should not be taken if you have recently used Levonelle or Levonorgestrel within the last 5 days. Please order Levonelle or Levonorgestrel.

11b. Please tell us which emergency contraception you took and when:

12. Have you been diagnosed with any of the following health problems?

  • Bowel or digestive disorders that’s causes malabsorption such as Crohn’s disease or ulcerative colitis
  • Liver disease
  • Prophyria
  • Ectopic pregnancy or had surgery to your fallopian tubes
  • Severe asthma treated with oral steroids

12b. Please provide more details:

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

13b. Please provide more details:

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

14b. Please provide more details:

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

15b. Please provide more details:

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

17. I understand that:

  • You must take the emergency contraceptive pill as soon as possible to have the best chance of it working.
  • Do a pregnancy test 3 weeks after unprotected sex to be sure you are not pregnant.
  • It is advisable to use a regular form of contraception to prevent future risk of pregnancy by completing our online assessment for oral contraception.
  • Emergency contraception does not prevent a pregnancy in every instance. It is NOT as effective as regular contraceptives, and therefore, you acknowledge that you must see my doctor to discuss further if further contraception is required.
  • Emergency contraception does NOT protect against sexually transmitted infections.
  • The copper intrauterine device (IUD) is the most effective method to prevent pregnancy after unprotected sex. It can be obtained by speaking to your GP doctor or a family planning clinic.
  • Taking emergency contraception may affect the date of your next period. If your period is more than 5 days late after taking Levonelle/ Levonorgestrel or 7 days late after taking ellaOne, please get in touch with a healthcare professional as you may be pregnant.
  • If you vomit within 3 hours of taking the pill, then it may not have been absorbed into my system, and you should seek the help of your doctor.

We try our best to help our patients, but sometimes, our online platform cannot meet all your needs. Please see your GP or go to a sexual health clinic if you:

  • Need help filling out forms, reading, writing or understanding complicated information
  • Are suffering from a severe mental health condition
  • Are you a victim of sexual assault or violence

18. Do you agree with the following?

  • You have read the information available on the treatments and medication (Levonelle, ellaOne) 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. Levonelle, ellaOne
  • You understand that although it is not compulsory, it is essential 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.

19. I confirm that I have read the information in this questionnaire and will follow the advice shown here and in the product leaflet