Better Meds

Do you believe you have the capacity to make decisions about your own healthcare?

Yes

Have you been diagnosed with any medical conditions?

Yes

Please provide more information, including diagnosis, symptoms and treatment.

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.

Yes

Please provide more information.

Do you suffer from any allergies?

Yes

What allergies do you have and what are the symptoms you experience from an allergic reaction?

Is there anything else you would like to include for the prescriber?

Yes

Please provide further information:

What is your blood pressure?

Low (below 90/60)

Normal (between 90/60 and 140/90)

High (above 140/90)

Not sure

When was your last blood pressure check (month/year)?

Are you currently using any kind of contraception (pill, ring, patch or other)?

Yes

What is the name of the contraception you used, and when did you stop using it and why?

Have you ever used the ring and/or the patch and/or the contraceptive pill before?

Yes

Do you ever have vaginal bleeding even when you are not on your period?

Yes

How long have you been experiencing this? Have you discussed this with your doctor or had an examination/treatment for this?

Do you smoke?

Yes

No - used to

How many cigarettes do you smoke per day?

Fewer than 15 a day

More than 15 a day

How long ago and how many per day?

Have you ever been told by a doctor that you have abnormal cholesterol?

Yes

Do you suffer from acne?

Yes

Have you tried any acne treatments?

Yes

What acne treatments have you tried?

Do you suffer from hirsutism (excessive female hair growth)?

Yes

Have you tried any hirsutism treatments?

Yes

Have you or anyone in your family ever had a blood clot?

Yes

Please provide further details

Have you had any major surgery in the last 3 weeks?

Yes

Please provide further details

Do you have a history of migraines?

Yes

Please provide details of your migraines, such as when your last attack was

Do you agree to the following?

You agree to our terms and conditions, privacy policy and acceptable use policy
You will read the Patient Information Leaflet supplied with your medication
The treatment is solely for your own use
You are aware you will be subject to a soft check to validate your identity via Yoti
You have answered all the above questions accurately and truthfully
You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You will inform your GP of this purchase if appropriate

Yes