About your condition and treatment
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
0%
Back
Are you aware of the following:
It is never a good idea to self-diagnose and treat urine incontinence.
Are you in need of an immediate emergency contraception?
Do you require assistance?
Is it possible that you're pregnant already (your menstruation is more than 5 days late)?
Do you require assistance?
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.
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)
Are there any issues about your relationship or sexual partner(s) that you'd like to talk to a healthcare expert about privately?
Are you willing to visit your doctor if:
Your symptoms are becoming more severe.
Do you have a history of using EllaOne?
Do you have a severe case of asthma?
Are you on any of the following medication?
Antibiotics.
Did you know that:
A healthcare practitioner should assess any acute injuries.
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.
What is your biological gender?
Please select your option
Date of Birth
Use the calendar to select your date of birth.
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924
Please add your height (in cms).
Your height is important for the prescribers decision.
Please add your current weight (in kgs).
Please make sure to add your current weight. This may affect the prescriber's decision.
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option
Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.
Can you relate to any of the following?
You have an underlying medical condition
Do you have a history of using levonorgestrel?
Do you experience the following problems?
Crohn's disease or ulcerative colitis are examples of small bowel diseases.
Do you have any recent or past medical history of note?
If yes, please provide details
Do you take any current or repeat medicines?
If yes, please provide details
Are you currently taking any other medicines including any herbal remedies? (e.g. St. John's Wort)
Do you suffer from malabsorption syndromes, bowel disease (e.g. Crohn’s disease), vomiting or diarrhoea?
If yes, please provide details
Do you have any liver problems?
If yes, please provide details
Have you had a serious reaction to ulipristal acetate (ellaOne) or levonorgestrel (Levonelle)?
If yes, please provide details
Have you had unprotected sex within the last 120 hours (5 days)?
Have you had unprotected sex within the last 72 hours (3 days)?
Have you had unprotected sex earlier in this menstrual cycle?
If yes, please provide details below
Was your last period late, longer/shorter or unusual in any way?
If yes, please provide details
Do you understand that if you vomit within 3 hours, another dose is required? You will need to come back or visit your doctor.
Have you already taken Levonelle or ellaOne since your last period?
Do you understand that If your next period is >3 days late or different in any way you should visit your doctor?
Do you have any allergies?
If yes, please provide details
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
Women only: Are you breast feeding?
Do you have any kidney problems?
If yes, please provide details
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
Do you have severe asthma?
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...
Please write below any further information which may be relevant e.g. medicines, conditions...
Next
