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To help us understand that this treatment is the right option for you, please answer the following questions.
This refers to your biological gender
Use the calendar to select your date of birth.
Your height is important for the prescribers decision.
Please make sure to add your current weight. This may affect the prescriber's decision.
This may have been by your GP or another healthcare professional, or by taking your own blood pressure on a home monitor.
Use the following as a guide:Low = Under 90/60Normal = Between 90/60 and 140/90High = Over 140/90
If you do, please write how many cigarettes you smoke per day. Or, if you vape, please tell us about this.
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
If yes, please provide the reason
If so, please provide more information
If you cannot, please provide more information
If yes, please provide details
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
If you do, kindly explain them below
Please list all your current prescription medication including any medication you buy over the counter.
If so, please provide more details
Please tell us in months e.g. 8 months
If yes, please provide details e.g. which pill, patch or other method
- Cerrazette- Cerrelle- Microgynon- Yasmin- Dianette- LoestrinIf you have been taking any others, please let us know which ones
This includes the morning after pill
- 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
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.
Unfortunately we cannot offer you any treatments for this condition. Please feel free to contact us for more information.