Contraceptive Pill Consultation

Are you female and over the age of 18 years? *

Yes No

Do you smoke? *

Yes No

Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? *

Yes No

Please provide more details

Have you ever had an allergic reaction to Desogestrel or any other contraceptive pill , Or have any other allergies we should be aware of ? *

Yes No

Please provide more details on ALL of your allergies

Do you suffer from migraines with aura, or a headache associated with weakness or numbness on one side of your face or body, or difficulty with speech? *

Yes No

Please provide more details

Do you or have you ever had or been diagnosed with any of the following?

Breast cancer
Liver cancer
Blood clot/thrombosis for example Deep vein thrombosis (DVT) or a Pulmonary embolism
Diabetes
Epilepsy
High blood pressure
Heart disease
Stroke or cerebro-vascular disease
Acute porphyria
Chloasma (a yellowish-brown pigmentation patches on the skin)

*

Yes No

Please provide more details

Are you taking any medications for the following conditions?

Epilepsy
Tuberculosis (e.g Rifampicin or Rifabutin)
HIV infections (e.g. ritonavir, nelfinavir, nevirapine, efavirenz)
Hepatitis C virus infection (e.g. boceprevir, telaprevir)
Any other infectious disease (e.g. griseofulvin)
High blood pressure in the blood vessels of the lungs (bosentan)
Depressive moods (e.g. St. John's Wort)
Certain bacterial infections (e.g. clarithromycin, erythromycin)
Fungal infections (e.g. ketoconazole, itraconazole, fluconazole)
High blood pressure (hypertension), angina or certain heart rhythm disorders (e.g. diltiazem)

*

Yes No

Please provide more details

Are you taking any other medication, including over the counter medicine, herbal medicine or recreational drugs? *

Yes No

Please provide more details

Would you like us to inform your GP of any treatment you receive from us? *

Yes No

Before you continue

Please read the following statements:

These questions have been answered truthfully and accurately to the best of my knowledge. I understand that any incorrect information may be detrimental to my health
The medication is for my personal use only and should be used as directed by the prescriber
I will read the patient information leaflet and contact a medical professional if I have any questions or experience any side effects while taking my medication
All information provided will be handle in the strictest confidence in line with the GDPR regulations and I am happy for Pharmacy to collect and use the information I provide for the purposes of prescribing medicines and to provide treatment for my medical condition
I am happy to be treated by the prescribers and health care professionals at Pharmacy and the final decision on whether to prescribe treatment will be with the prescriber
I understand there have been reports of patients developing depression or depressed mood whilst on contraception medication. If I experience mood changes or depressive symptoms, I agree to contact my doctor for further medical advice as soon as possible
I confirm I am currently not pregnant or there is no possibility that I may be pregnant
I will contact my doctor if I notice any possible signs of a blood clot; sudden, severe stomach ache or jaundice; or sudden or severe pain in the lower abdomen or stomach area; a lump in my breast; unusual or heavy vaginal bleeding or that I may be pregnant

I agree to all of the above statements