Consultation

Are you over 16?

Have you had unprotected intercourse in the last 24 hours? (it is OK to use within 72 hours for Levonelle or 120 hours for ellaOne, but we are taking delivery time into consideration)
Do any of the below apply to you (lack of Protection Due to)?
*Absence of Contraception
*Failure of Barrier Method
*Pill Error
*Reduced Pill Efficacy due to Vomiting or Diarrhoea
*Reduced Pill Efficacy due to Concurrent Medication
*Vomiting within 3 Hours of taking EHC

I am aware of the following:
• Levonelle is effective if it is taken within 72 hours of unprotected intercourse and EllaOne is most effective for up to 120 hours (5 days). Levonelle may be used between 72 and 96 hours after unprotected intercourse but efficacy decreases with time. If you require the morning after pill immediately you should realise that there may be a delay (depending on your chosen delivery option) before your emergency pill arrives. This means that you risk getting pregnant.
• If you need the morning after pill immediately you should visit your GP. Alternatively, you can go to your local pharmacy where you can purchase the morning pill over the counter.

Have you ever had a reaction or allergy with the contraceptive pill or other hormonal medication?

Do any of the below apply to you?
*Was the last period later than the expected time?
*Was the last period lighter or shorter than normal?
*Was the last period unusual in any way?
*Has Unprotected Sexual Intercourse taken place since last period?

Do any of the below apply to you?
*Is there a history of allergy to Levonorgestrel?
*Is there a history of liver disease?
* Previous ectopic pregnancy, fallopian tube surgery or pelvic inflammatory disease
* Lactose intolerance
* Women with severe asthma treated by oral glucocorticoid
* Is there a history of malabsorption syndrome e.g. Crohn’s Disease?
* Is there a history of porphyria?
* Is there a history of unexplained/unusual vaginal bleeding?

Are you taking any of the following medications?
• Barbiturates, Primidone, Phenytoin, fosphenytoin, Carbemazepine, oxcarbazepine, (used predominantly to treat epilepsy)
• Rifampicin or Rifabutin (tuberculosis)
• efavirenz, nevirapine or Ritonavir (for HIV infection)
• Griseofulvin (for fungal infections)
• Ciclosporin
• Herbal remedies containing St John’s Wort, Hypericum perforatum
• Antacids and anti-ulcer medication

Are you aware that ‘morning after pills’ may not be 100% effective??
• When taken in the first 3 days after intercourse, pregnancy rates are close to 1.5 in 100 (ellaOne) or 2 in 100 (Levonelle)
• Levonelle can be taken up to 3 days and ellaOne up to 5 days after intercourse.

Is there a chance that you may already be pregnant?
• This could be indicated by changes or interruptions to your menstrual cycle.
• Levonelle will NOT terminate an existing pregnancy

Are you breast feeding?

Are you aware Levonelle and ellaOne should NOT both be taken in the same menstrual cycle (period)?
• Take either Levonelle or ellaOne, NOT both.
• Levonelle and ellaOne should also NOT be taken more than once in the same cycle (period).

Are you aware:
• If vomiting occurs within three hours of taking the tablet, another tablet should be taken immediately.
• After using emergency contraception it is recommended to use a barrier method (e.g. condom, diaphragm or cap) until the next menstrual period starts.
• That emergency contraceptive medications may cause menstrual cycle disturbances which can sometimes lead to earlier or late periods.
• If menstrual periods are delayed by more than 5 days or abnormal bleeding occurs at the expected date of menstrual periods or pregnancy is suspected for any other reason, a pregnancy test should be conducted.
• The use of emergency contraception does not replace the necessary precautions against sexually transmitted diseases. If you develop pelvic pain, experience any vaginal discharge or a high temperature after unprotected intercourse you must seek medical advice.
• Use of Levonelle 1500 or ellaOne 1500 does not contraindicate the continuation of regular hormonal contraception.
• That levonelle and ellaone will both reduce the effectiveness of the regular ‘pill’, if you wish to start or continue using hormonal contraception, you must use a reliable barrier method until the next menstrual period.
• ellaOne may have minor or moderate influence on the ability to drive or use machines whilst Levonelle should not, however, if you feel tired or dizzy do not drive or operate machinery.

I confirm that:
• I have answered the online medical assessment truthfully and understand that not doing so may be dangerous and to the detriment of my own health.
• I understand that the morning after pill is more effective the sooner I take it after unprotected sexual intercourse.
• I understand the possible side-effects of the morning after pill.
• I understand the importance of long-term methods of contraception and that the morning after pill will not protect me against sexually transmitted infections.
• I agree to read the patient information leaflet that will accompany the medicine.
• I am female and this medication is for my own use.
• I will seek medical attention immediately if I experience any unusual side effects.

What is the name of your GP surgery and do you consent to us contacting them about your treatment?

Do you consent to us accessing your GP records? This is advised so we can clinically assess suitability.