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.
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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?
What is your D.O.B (dd/mm/yyyy)
Is it possible that you're pregnant already (your menstruation is more than 5 days late)?
Do you require assistance?
What is your Height in Centimetres
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.
What is your weight in Kilograms
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
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...
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The Agreement
Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.
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Is this treatment for yourself?
Are you requesting Emergency contraception following unprotected sexual intercourse?
Did sexual intercourse occur within the last 72 hours?
Is there any chance you may already be pregnant?
This includes the following scenarios:
Since your last period have you used emergency contraception (morning after pill)?
Have you ever been diagnosed with other medical conditions?
This includes but is not limited too things such as:
Are you currently pregnant, planning a pregnancy or breastfeeding?
Do you suffer with any allergies?
Do you currently take any medication? This includes herbal remedies and over the counter medication.
Is there any other information you would like to share with our prescribing team?
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