What we treat
Men's Health
Erectile Dysfunction
Premature Ejaculation
Hair Loss
Women's Health
Period Delay
Combined Pill
Mini Pill
Alternatives to the pill
General Health
Asthma
Migraine
Acid Reflux
Weight Loss
0
Alternatives to the pill
What was your assigned sex at birth?
Male
Female
Have you ever experienced an allergic reaction or undesirable side effect from any hormonal contraceptive?
Yes
No
Please specify the undesirable side effects or allergic reactions you experienced.
Please state the name of the contraceptive(s) causing the side effects or allergic reactions.
Please provide your most recent blood pressure readings.
Normal (Between 90/60 and 139/89)
Low (Below 89/59)
High (Above 140/90)
I know my exact readings
Not Sure
Please provide your exact readings.
When did you last have a smear test?
Within three years
Within five years
More than five years ago
Never had one
Do you get any unexpected bleeding?
Bleeding in-between periods
Bleeding after sex
None of the above
Have you already seen your GP about this?
Yes
No
Because you haven't seen your GP yet about your unexpected bleeding, please do the following:
See your GP in the next 2 weeks and let us know the outcome
Do a pregnancy test as soon as possible
I Understand
Do you smoke?
No - never smoked
No - used to smoke
Yes
How many cigarettes do you smoke per day?
Less than 15
15 or more
Have you ever been diagnosed with any of the following?
Migraines
Severe headaches
Yes
No
Are you due to have any major surgery or have you had major surgery in the past three months?
Yes
No
Please provide more information.
Do you have any problems with your mobility?
Yes
No
Please provide more information.
Have you ever had cancer?
Yes
No
Please provide more information.
Do you take any other medicines including prescription, over-the-counter or recreational drugs?
Yes
No
Please provide the name and dose of all medicines you are currently taking.
Do you have any allergies?
Yes
No
Please provide more information.
Have you ever had any medical conditions or surgery not previously mentioned in this form, or is there any further information you would like to provide the doctor?
Yes
No.
Please provide more information.
Do you understand the following?
Contraception is not 100% effective.
You should only use this product if you confirm you are not pregnant.
You should use condoms or abstain from sex until the contraception becomes effective.
Unprotected sex puts you at risk of sexually transmitted infections. It is important to get tested regularly, especially if you have a new partner or have had more than one partner in the last 12 months.
I understand
Please confirm you will see your GP for a physical review if you are frequently experiencing any unexpected vaginal bleeding after sex, midcycle or irregular bleeding. This could be a sign of a serious medical condition such as an infection, or possibly a cancer.
I confirm
Submit
What we treat
Men's Health
Erectile Dysfunction
Premature Ejaculation
Hair Loss
Women's Health
Period Delay
Combined Pill
Mini Pill
Alternatives to the pill
General Health
Asthma
Migraine
Acid Reflux
Weight Loss
