Contraceptives

Are you a female (from birth) between 18 to 49 years old? *

What is your height? *

What is your weight? *

Your BMI *

Have you had your blood pressure checked within the last three months? Please provide you blood pressure reading if known *

Are you pregnant, or might you be pregnant? *

When was the date of your last menstrual period? Was it normal for you? *

Date *

Have you had an unprotected sex since your last menstrual period? *

Are your menstrual cycles regular? *

Do you experience heavy or painful periods? *

Do you experience any unexplained bleeding from your vagina? *

Do you have any known medical conditions? *

Cardiovascular health - Does any of the following applies to you? *

• Current or past history of ischaemic heart disease, vascular disease, stroke, or transient ischaemic attack (TIA)
• Diabetes and has it affected any of your organs (causing retinopathy, nephropathy, or neuropathy)
• Current or past history of deep vein thrombosis or pulmonary embolus
• Known thrombogenic mutations e.g., factor V Leiden, prothrombin mutation, protein S, protein C and antithrombin deficiencies
• Current or past history of any heart disease
• Parents, siblings or children who have had heart disease or strokes under the age of 45
• Parents or siblings that have had a deep vein thrombosis or pulmonary embolus under the age of 45
• Blood clotting illnesses / abnormalities
• Any problems with your heart muscle or any impaired heart function
• Diagnosed with atrial fibrillation
• Multiple risk factors for cardiovascular disease (CVD) (such as hypertension and high level of cholesterol or triglycerides)

Neurological health - Does any of the following applies to you? *

• Current or past history of migraines with visual symptoms or changes in sensation or muscle power on one side of your body
• Migraines without aura, first attack occurred when on a method of contraception containing estrogen
• Current or past history of meningioma

Cancers - Does any of the following applies to you? *

• Past or current history of breast cancer or cancer of the genital organs
• Carrier of known gene mutations associated with breast cancer e.g. BRCA1 or 2
• Undiagnosed breast symptoms
• Family history of breast cancer under the age of 50
• Malignant liver tumour (hepatocellular carcinoma)

Gastro-intestinal health - Does any of the following applies to you? *

• Viral hepatitis, acute or flare
• Benign liver tumour (hepatocellular adenoma)
• Liver disease or liver impairment
• Gall bladder disease that causes you symptoms or is medically managed
• Acute/active inflammatory bowel disease or Crohn’s disease
• Had any bariatric surgery or any other surgery that has reduced your ability to absorb things from your stomach
• Cholestasis, a condition caused by blocked or reduce flow of bile fluid (related to past combined hormonal contraceptive use)

Other Health Conditions - Does any of the following applies to you? *

• Any recent or planned major surgeries or immobility
• Diagnosed with Anti phospholipid syndrome (APS) (also known as Hughes syndrome) with or without Lupus
• Had an organ transplant that has resulted in complications
• Severe kidney impairment or acute renal failure
• Diagnosed with Acute porphyria

Are you breast-feeding? *

Post-Partum – Does any of the following applies to you? *

• Less than 21 days after child birth (for deliveries over 24 weeks gestation)
• Breast-feeding and less than six weeks post-partum
• Not breast-feeding and less than 6 weeks post post-partum with other risk factors for venous thromboembolism (VTE)

Are you taking any medication (including over-the-counter or herbal products)? *

Are you taking any of the following: *

• Antibiotics:
  • Rifampicin (potent inducer).
  • Rifabutin.
• Antiepileptics:
  • Carbamazepine.
  • Eslicarbazepine.
  • Oxcarbazepine.
  • Phenytoin.
  • Phenobarbital.
  • Primidone.
  • Rufinamide.
  • Lamotrigine.
  • Topiramate (weak inducer).
• Antiretrovirals:
  • Protease inhibitors: ritonavir, atazanavir, darunavir, fosamprenavir, lopinavir, nelfinavir, saquinavir, and tipranavir.
  • Non-nucleoside reverse transcriptase inhibitors: efavirenz, nevirapine.
  • Always use the HIV Drug Interaction Checker to identify potential interactions.
• Others:
  • Bosentan.
  • Ciclosporin.
  • Modafinil.
  • Aprepitant.
  • Griseofulvin.
  • Vemurafenib.
  • St John’s Wort.

Do you have any known allergies or intolerance or previous reactions to contraceptive methods? *

Are you a smoker (including vaping / use of e-cigarettes) or ex-smoker? *

Number of cigarettes/day: *

What are your preferences or concerns about contraception? (e.g., ease of use, periods, side effects, long-acting methods) *

Have you previously used any of the following contraceptive methods? *

Select any of the following contraceptive methods *

Are you wanting to change your current contraceptive pill? *

Have you experienced any side effects or adverse reactions from previous use of oral contraceptives? *

Since your last supply, have you missed any pills or had any break in taking them? *

Are you concerned about STI risk? Would you like to be tested for STIs? *

I understand I should use condoms in addition to contraceptive pills to protect myself from sexually transmitted infections (STIs), and I may request STI screening if needed. *

I understand no contraceptive method is 100% effective and I can get pregnant if I missed the pill. *

I understand I should stop taking the contraceptive pill and seek medical help urgently if I experience calf swelling, heat or pain in the calf, shortness of breath, chest pain or haemoptysis. *

I understand I should seek advice if I experience their first ever migraine or develops aura with existing migraine. *

I understand combined hormonal contraceptives is associated with a small risk of breast cancer which reduces with time after stopping. *

I understand with the use of combined hormonal contraceptives for more than 5 years is associated with a small increased risk of cervical cancer, risk which reduces over time after stopping and is no longer increased by about 10 years after stopping. *

I understand combined hormonal contraceptives is associated with an increased risk of VTE/ATE. I should stop taking the tablets and seek medical advice immediately if I experience any of the following symptoms of blood clots: *

Symptoms of a blood clot in the lungs:

• Sudden, severe, sharp pain in your chest
• Coughing up blood
• You suddenly become short of breath
• Your heart beats more rapidly

• You have an unusually severe or long headache
• Your sight is affected in any way
• You find it difficult to breathe
• Any part of your body feels weak or numb

• You have severe pain, tenderness or swelling in your calf, ankle or foot
• You have purple discolouration of skin of the leg or the skin becomes red and warm to touch

I understand I should reduce periods of immobility during travel with the use of combined hormonal contraceptives *

I understand if I plan to travel to high altitudes (above 4,500 metres / 14,500 feet) for more than one week, I may need to switch to a safer contraceptive method to reduce health risks *

I understand that I need to stop taking the combined pill at least 4 weeks before any planned major surgery or period of limited mobility, and that I will speak with my doctor about suitable alternative contraceptive options. *

I understand that if I vomit within 3 - 4 hours after taking the pill or have severe diarrhoea, or miss any pills, I should follow the guidance provided in the Patient Information Leaflet (PIL) or seek advice from my prescriber. *

I understand that if I experience changes in mood or symptoms of depression, I should contact my doctor as soon as possible for further medical advice *

I understand that if I do not experience the expected withdrawal bleeding for two consecutive cycles, I may be pregnant and should contact my doctor immediately. I will not start the next strip until pregnancy has been ruled out. *

I understand before starting any new medicine or herbal product (including over-the-counter or online purchases), I should check with a doctor, pharmacist, or prescriber to make sure it’s safe to use with the pill. *

Can we share this information with your General practitioner? 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 contact your regular prescriber if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records. *

To ensure your medication is prescribed safely, our clinical team may need to: *

• Access your medical records (including your Summary Care Record, where applicable)
• Invite you to take part in a follow-up phone or video consultation for further clarification

Do you agree to the following? *

• You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health
• You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable
• You will inform your doctor about any unusual side effects
• The treatment is solely for your own use
• You will read the patient information leaflet supplied with your medication
• You will not exceed the maximum daily dose of this medication
• You confirm you have the capacity to make decisions about your own health