Emergency Contraception

1. About your Health

Your health and safety are our top priorities. To ensure we provide you with the most effective and appropriate treatment, it is crucial that you provide accurate and complete information about your health during our online consultation process. Accurate information helps us understand your condition better, assess any potential risks, and recommend the best possible medication for your needs. Providing false or incomplete information can lead to inappropriate treatment, potential health risks, and delays in receiving the care you need. Thank you for your cooperation and trust in our services.

What is your Date of Birth?

Please use the following format 00/00/0000

What's your gender?

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

Do you have any known allergies?

If yes, please list them.

Yes

Are you currently taking any medications?

If yes, please list them.

Yes

Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

If yes, please list them:

Yes

Have you had any surgeries in the past year?

If yes, please provide details:

Yes

Do you smoke?

Yes

Do you consume alcohol?

If yes, how often?

Yes

How often do you exercise?

Daily

Weekly

Rarely

Never

What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

2. About your Condition

Accurately describing your condition during our online consultation is essential for ensuring you receive the best possible care. Detailed and truthful information about your symptoms, their frequency, and their severity allows our healthcare professionals to make informed decisions about your treatment. Incomplete or incorrect descriptions can result in inappropriate medication, potential health risks, and delays in your care. Your honesty and thoroughness help us provide you with the most effective and safe treatment options. Thank you for your cooperation and trust in our services.

When did the unprotected intercourse or contraceptive failure occur? (Please provide date and time)

Was the intercourse consensual?

Yes

Are you currently using any form of regular contraception?

If yes, please specify:

Yes

Have you used emergency contraception before?

If yes, please provide details (e.g., type of emergency contraception, any side effects experienced):

Yes

When was the first day of your last menstrual period?

Are your menstrual cycles regular?

Yes

Have you experienced any changes in your menstrual cycle recently?

If yes, please describe:

Yes

Is there a possibility that you could already be pregnant?

Yes

Have you had any recent symptoms of pregnancy (e.g., nausea, breast tenderness, missed period)?

Yes

Are you currently experiencing any symptoms that concern you?

If yes, please describe:

Yes

Do you have any health conditions that might be affected by taking emergency contraception? (e.g., liver disease, blood clotting disorders)

If yes, please specify:

Yes

3. The Agreement and Consent

Please take the time to carefully read the Agreement and Consent statements during our online consultation process. Understanding these statements is essential for your safety and for ensuring that you are fully informed about the treatment you will receive. The Agreement and Consent sections outline important information about the risks, benefits, and responsibilities associated with your medication. By reading and agreeing to these terms, you help us ensure that you are aware of and comfortable with the treatment plan. Your informed consent is crucial for providing you with the best possible care. Thank you for your cooperation and trust in our services.

Understanding of Risks:

I have been informed about the potential side effects and interactions of the prescribed medication for Contraception.

Yes

Medical Guidance:

I agree to consult with my healthcare provider before starting any new medication.

I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

Yes

Consent to Share Information:

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

I understand that my information will be kept confidential and used solely for the purpose of this assessment.

Yes

Confirmation:

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have health implications.

Yes

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