Emergency Contraception

Are you aware of the following:
It is never a good idea to self-diagnose and treat urine incontinence.
At the very least, you should see your doctor for a checkup once a year.
You must follow your doctor's instructions for any treatment.
You should only order repeat supplies of medicines that your doctor has prescribed.

Yes

No

Are you in need of an immediate emergency contraception?
Do you require assistance?

Yes

No

Is it possible that you're pregnant already (your menstruation is more than 5 days late)?
Do you require assistance?

Yes

No

Are you aware of the following?
It has been proven that taking more than the suggested amount of a hair loss therapy does not boost its effectiveness.
If your spouse is pregnant or could become pregnant, you should use a condom during any sexual activity and don't let them handle hair loss therapy.
If you need a PSA blood test, notify your doctor that you are taking hair loss treatment because it may impact the findings.
If you have any unusual side effects while taking finasteride or dutasteride, you should consult your doctor. These include breast tissue changes such as lumps, larger breasts, discomfort or nipple discharge, a decreased libido, erectile dysfunction, and ejaculation disorders, as well as a decreased libido, erectile dysfunction, and ejaculation disorders.

Yes

No

Are the following conditions something you have experienced before or has a doctor ever diagnosed you with any of them?
Severe gastrointestinal issues (such as Crohn's disease and ulcerative colitis)
Ectopic pregnancy, fallopian tube surgery, or pelvic inflammatory illness.
Do you require assistance?

Yes

No

Are there any issues about your relationship or sexual partner(s) that you'd like to talk to a healthcare expert about privately?

Yes

No

Are you willing to visit your doctor if:
Your symptoms are becoming more severe.
After seven days of medication, the symptoms have not improved.
Continuous rectal bleeding, dark or sticky feces, stomach pain, or sudden weight loss are all symptoms you're experiencing.

Yes

No

Do you have a history of using EllaOne?

Yes

No

Do you have a severe case of asthma?

Yes

No

Are you on any of the following medication?
Antibiotics.
Antihistamines such as stemizole or terfenadine.
Cisapride for stomach discomfort.
Quinidine for circulatory problems.
Pimozide for schizophrenia.

Yes

No

Did you know that:
A healthcare practitioner should assess any acute injuries.
You should see your doctor about chronic pain at least once a year.

Yes

No

Can you relate to any of the following statements?
You have or have had stomach or duodenal ulcers, as well as stomach or intestinal bleeding in the past.
Your doctor has ever told you that your kidney function is less than 100 percent.
You have previously suffered a terrible reaction to aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs).
You want to use Ibuprofen Gel on skin that is fractured, injured, diseased, or infected.

Yes

No

What is your biological gender?
Please select your option

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

No

Can you relate to any of the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

No

Do you have a history of using levonorgestrel?

Yes

No

Do you experience the following problems?
Crohn's disease or ulcerative colitis are examples of small bowel diseases.
An ectopic pregnancy history.
Salpingitis in the past (inflammation of the Fallopian tubes).

Yes

No

Do you have any recent or past medical history of note?
If yes, please provide details

Yes

No

Do you take any current or repeat medicines?
If yes, please provide details

Yes

No

Are you currently taking any other medicines including any herbal remedies? (e.g. St. John's Wort)

Yes

No

Do you suffer from malabsorption syndromes, bowel disease (e.g. Crohn’s disease), vomiting or diarrhoea?
If yes, please provide details

Please provide details in this box here...

Yes

No

Do you have any liver problems?
If yes, please provide details

Yes

No

Have you had a serious reaction to ulipristal acetate (ellaOne) or levonorgestrel (Levonelle)?
If yes, please provide details

Please provide details in this box here...

Yes

No

Have you had unprotected sex within the last 120 hours (5 days)?

Yes

No

Have you had unprotected sex within the last 72 hours (3 days)?

Yes

No

Have you had unprotected sex earlier in this menstrual cycle?
If yes, please provide details below

Please provide details in this box here...

Yes

No

Was your last period late, longer/shorter or unusual in any way?
If yes, please provide details

Yes

No

Do you understand that if you vomit within 3 hours, another dose is required? You will need to come back or visit your doctor.

Yes

No

Have you already taken Levonelle or ellaOne since your last period?

Yes

No

Do you understand that If your next period is >3 days late or different in any way you should visit your doctor?

Yes

No

Do you have any allergies?
If yes, please provide details

Yes

No

Are you aware that the use of emergency contraception does not replace the necessary precautions against sexually transmitted diseases?
Please speak to your pharmacist if you require further counselling

Yes

No

Women only: Are you breast feeding?

Yes

No

Do you have porphyria?

Yes

No

Do you have any kidney problems?
If yes, please provide details

Please provide details in this box here...

Yes

No

Have you been told by your doctor you have an intolerance to any sugars (e.g galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)?
If yes, please provide details

Please provide details in this box here...

Yes

No

Do you have severe asthma?

Yes

No

Have you previously had an ectopic pregnancy, gestational trophoblastic tumours or salpingitis?
Please write below any further information which may be relevant e.g. medicines, conditions...

Yes

No

Please write below any further information which may be relevant e.g. medicines, conditions...

All Conditions

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