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Morning After Pill

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 enquiries@thefamilychemist.co.uk

About You

1. Are you purchasing this medication for yourself?
2. Are you female and over 18 years old?
3.Enter your height Foot Inches
4.Enter your weight st lb
3.Enter your height Cms
4.Enter your weight KGs

5. Your BMI is:

The emergency contraception containing levonorgestrel may be less effective for women who weigh more than 70 kg or have a BMI greater than 26 kg/m. If your BMI is greater than 26 or you weigh more than 70kg, then you should use ellaOne.

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

Please tell us how many weeks pregnant you are:

Medical History

7. Why do you need emergency contraception?

Please provide more details:

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

date: time:

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.

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

Please provide more details:

10. 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 3 weeks after unprotected sex.

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

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

Please tell us which emergency contraception you took:

13. 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

Please provide more details:

Past Medical History

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

Please provide more details:

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

Please provide more details:

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

Please provide more details:

17. Are you currently breastfeeding?

It is safe to take Levonelle, Levonorgestrel during breastfeeding however, if you prefer ellaOne you must not breastfeed for 5 days after taking.

18. Would you like us to contact your GP?

19. 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
  • The emergency contraception is an effective way of making sure you do not become pregnant after unprotected sex or contraception failures. Emergency contraception does not prevent a pregnancy in every instance. It is NOT as effective as regular contraceptives and therefore acknowledge that I must see my doctor to discuss further.
  • The 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 and 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 contact a healthcare professional as you may be pregnant.
  • If I vomit within 3 hours of taking the pill then it may not have absorbed into my system and I should seek the help of my doctor.
  • We try our best to help our patients, but sometimes our online platform is not able to 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 with a severe mental health condition
  • Are a victim of sexual assault or violence

20. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at enquiries@thefamilychemist.co.uk so we can talk through your options.

  • 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 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.

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

Please click "Yes".