Contraception

Complete assessment form

To help us understand that this treatment is the right option for you, please answer the following questions.

1

Please state your gender

This refers to your biological gender

Male

Female

2

Date of Birth

Use the calendar to select your date of birth.

3

Please add your height (in cms).

Your height is important for the prescribers decision.

4

Please add your current weight (in kgs).

Please make sure to add your current weight. This may affect the prescriber's decision.

5

Have you ever been told that you have high or low blood pressure?

This may have been by your GP or another healthcare professional, or by taking your own blood pressure on a home monitor.

Yes

No

6

Do you know if your blood pressure is Low, Normal or High? Please write LOW, NORMAL or HIGH

Use the following as a guide:

Low = Under 90/60
Normal = Between 90/60 and 140/90
High = Over 140/90

7

Do you smoke?

If you do, please write how many cigarettes you smoke per day. Or, if you vape, please tell us about this.

Yes

No

8

Do you drink alcohol?

If so, please tell us how many units per day. You can use the following as a guide:

- Pint of beer = 3 units
- A can of beer = 2 units
- A large glass of red wine = 3 units

Yes

No

9

Have you been advised to avoid strenuous exercise?

If yes, please provide the reason

Yes

No

10

Is walking or running difficult for you?

If so, please provide more information

Yes

No

11

Can you walk 3 miles or climb a set of stairs without pain in your chest?

If you cannot, please provide more information

Yes

No

12

Do you have any recent or past medical history of note?

If yes, please provide details

Yes

No

13

Are you experiencing any of the following health issues?

You've had a heart procedure, a stroke, or a heart attack in the last five years. You have angina, aortic stenosis, heart failure, cardiomyopathy, high blood pressure that is uncontrolled (greater than 160/90), arrhythmia, or severe heart disease. You have suffered low blood pressure, fainting, or feeling dizzy when you stand up after lying down in the past. Diabetes (type I or type 2) or blood sugar levels that are abnormal. Medical diseases that impact the eyes, such as glaucoma or degenerative eye disease, as well as a family history of these conditions. Peyronie's disease is a deformity or angulation of the penis. Sickle cell disease, leukemia, or multiple myeloma are all examples of blood cancers. A disease that causes bleeding

Yes

No

14

Do you suffer from any allergies?

If you do, kindly explain them below

Yes

No

15

Do you currently take any medication whatsoever?

Please list all your current prescription medication including any medication you buy over the counter.

Yes

No

16

Is there a history of medical disorder's within your family?

If so, please provide more information

Yes

No

17

Have you ever had any surgery (operations)?

If so, please provide more details

Yes

No

18

Are there any other health/medical details you feel we should know?

If so, please provide more information

Yes

No

Complete assessment form

To help us understand that this treatment is the right option for you, please answer the following questions.

19

How long have you used hormonal contraception (pill or patch) in total?

Please tell us in months e.g. 8 months

20

Are you currently using any form of contraception?

If yes, please provide details e.g. which pill, patch or other method

Yes

No

21

Have you had a check-up with your doctor/nurse about your contraceptive pill in the last year?

If yes, please provide details

Yes

No

22

Are you currently taking, or have you taken, any of the following contraceptive pills?

- Cerrazette
- Cerrelle
- Microgynon
- Yasmin
- Dianette
- Loestrin

If you have been taking any others, please let us know which ones

Yes

No

23

Have you experienced any side effects from any contraceptives you have taken?

This includes the morning after pill

Yes

No

24

Have you ever been told not to take hormonal contraception (pills or patches) or are you aware of any reason why you shouldn't?

Yes

No

25

Are you having any problems with your current contraceptive pill such as irregular bleeding/periods?

If yes, please provide details

Yes

No

Complete assessment form

To help us understand that this treatment is the right option for you, please answer the following questions.

26

Do you agree to the following?

- You declare that I have answered the above truthfully
- You will read the patient information leaflet before taking your medication (if prescribed)
- You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment
- You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
- You understand that this questionnaire is part of a request to the doctor and the final decision will rest with the doctor

Yes

No

27

Would you like a free face to face consultation with our Doctor via Skype video?

Yes

No

28

Can we share this information with your General practitioner?

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.

Yes

No

Want your order delivered tomorrow?

For next day delivery please order in next:

09

hrs

57

mins

52

secs

Unfortunately we cannot offer you any treatments for this condition.
Please feel free to contact us for more information.

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Complete assessment form

Complete assessment form

Complete assessment form