Morning After Pill Assessment | Pharma Aesthetics

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Morning After Pill Treatment Medical Questionnaire

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Step 1 of 8

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Ordered Before?

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You can order again by selecting the product from your dashboard, clicking Order Again.

Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Morning After Pill Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

Have you had unprotected sexual intercourse or experienced contraceptive failure (e.g., broken condom) within the last 72 hours?*

Yes

No

Please provide more information below.*

Are you seeking emergency contraception as a precaution against unplanned pregnancy?*

Yes

No

Please provide more information below.*

Have you used the morning-after pill on any previous occasion within this menstrual cycle?*

Yes

No

Please provide more information below.*

Do you suspect that your regular form of contraception may not have been effective?*

Yes

No

Please provide more information below.*

Are you unable to use standard contraceptive methods at this time?*

Yes

No

Please provide more information below.*

Health

Are you aware that the morning-after pill is not intended as a regular form of contraception and should only be used in emergencies?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any known allergies to the components of the morning-after pill, such as levonorgestrel or ulipristal acetate?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you currently taking any medications that could potentially interact with the morning-after pill, including certain epilepsy treatments, TB treatments, or herbal remedies like St. John’s Wort?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you been diagnosed with any medical conditions that could affect the effectiveness of the morning-after pill, such as severe liver dysfunction?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you breastfeeding, understanding that while it's generally considered safe, there may be specific advice to follow when taking the morning-after pill?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions aim to ensure the safe and appropriate use of the morning-after pill, taking into account the patient's immediate needs and overall health condition.

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Phone

This field is for validation purposes and should be left unchanged.

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16 Broadway, Rainham, Essex, RM13 9YW
01708 608860
info@pharma-aesthetics.co.uk

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