Contraception Form Contraception Form Patient InformationHealth History Book an appointmentCovid-19 VaccineConsent Welcome to the Contraception FormWhat type of contraception would you like? Morning_After_Pill Regular_ContraceptionIs this the first time you complete this form? First Time Repeat PatientPreviousNextFirst NameLast NameEmailPhone/MobileAddress Line 1CityPostcodeCountryUnited KingdomUnited Kingdom (UK)Date of birth Assigned Sex at birth Male FemalePreviousNextIs this your first time starting the contraceptive pill, or are you looking to restart it after a break? First time Restarting or switching hormonal contraceptionWhat contraception were you using previously?How Long ago did you stop this form of contraception?Current Medication DetailsHave you had any side effects or issues with your previous form of contraception? Yes NoPlease describeAre you experiencing any side effects from your current contraceptive? Yes NoPlease describeAre you taking any other prescribed medicines Yes NoPlease list what medicines you currently take Do you take any over-the-counter or herbal products Yes NoPlease list what products you currently take When did you have unprotected sex? Earlier Today Yesterday Before Yesterday Please provide details of the exact date and time Have you had any changes in your medical history since your last consultation (e.g., new diagnoses, surgeries)? Yes NoPlease describeAre you taking any new medications (prescription, over-the-counter, or herbal supplements)? Yes NoPlease describeHave you experienced any of the following since starting your current contraceptive Severe headaches or migraines Unusual or heavy bleeding Chest pain or shortness of breath Swelling or pain in your legs Yellowing of the skin or eyes (jaundice) Changes in vision or speechHave you had any difficulty remembering to take your contraceptive? Yes NoAre you planning to become pregnant in the near future? Yes NoDo you have any concerns or questions about your current contraceptive method? Yes NoPlease describeWhat are your reasons for requesting emergency contraception? Broken condom No contraception was used Missed a pill of my regular contraception Just started contraception and it is not yet affective I have been sexually assaulted Other Please provide detailsHave you taken any other Morning after pills or hormone pills in the last 7 days No, I have not taken any Yes, I took EllaOne less than 7 days ago Yes, I took Levonelle or Levonorgestrel less than 7 days ago Just started contraception and it is not yet affective Yes, I have taken other hormonesPlease Expand what form it was e.g. HRT, period delay pills or regular contraception pills Do you usually get a period Yes NoWhen is your next period due My period is due within the next 7 days My period is due in 1-3 weeks My period is due in 3+ weeks I don’t know when my period is due Have you experienced any of the following Miscarriage or abortion in the last 5 days Previous ectopic pregnancy Given birth in the last 21 days None of the aboveAre you, or might you be pregnant? Yes No Might be UnsureAre you currently a smoker Yes, currently smoking No, quit smoking No, never smoked Do you suffer from, or have a family history of heart conditions Yes No UnsureDo you or your family have a history of cancer? Yes No UnsureDo you suffer from migraines? Yes, diagnosed with migraines Yes, undiagnosed with migraines NoWhat is your height What is your weightAre you currently breastfeeding? Yes NoDo you have any health conditions or/and take any medications? Yes NoPlease explain your conditions/medicationsDo you have any allergies? Yes NoPlease detail your allergiesHave you recently had your blood pressure measured Yes NoWhat was your most recent blood pressure reading? Would you like to book a blood pressure check at The Kingston Pharmacy? Yes NoSelect Appointment Date & TimeDo you have a preference for what type of contraceptive pill to start Yes, prefer the combined pill Yes, prefer the progesterone-only pill (mini Pill) No Preference Do you have a brand preference for what type of contraceptive pill to startAny other notes/comments to be considered by the healthcare professionalPreviousNextPreferred Method of Medication Delivery Pick up at The Kingston Pharmacy (Free) Home delivery (£2.99)Is the delivery address the same as your home address Yes NoAddress Line 1CityPostcodeCountryUnited KingdomUnited Kingdom (UK)Are you under the age of 25? Yes NoYour treatment is FREE!Text InputYou have two options EllaOne (Ulipristal Acetate) LevonorgestrelSelect Appointment Date & TimeSelect Appointment Date & TimePreviousNextVaccine Information and Consent Covid vaccine - Please read the following information carefully: Common side effects: Pain at the injection site, headache, fatigue, fever, muscle pain, chills, and nausea. Serious side effects: Severe allergic reactions are rare but can occur. The COVID-19 vaccine is recommended to protect against the coronavirus disease (COVID-19), a contagious respiratory illness caused by the SARS-CoV-2 virus. The vaccine is usually given as an injection in a series of doses, depending on the specific vaccineVaccine Information and Consent Flu vaccine - Please read the following information carefully: Common side effects: Pain at the injection site, headache, fever, muscle aches, and mild fatigue. Serious side effects: Severe allergic reactions are rare but can occur. The Influenza vaccine is recommended to protect against the flu, a contagious respiratory illness caused by influenza viruses. The vaccine is usually given as an injection. I have read the information about the COVID-19 vaccine. I understand the benefits and risks of the COVID-19 vaccine and request that the vaccine be given to me or to the person named above for whom I am authorised to make this request. I have read the information about the Influenza vaccine. I understand the benefits and risks of the Influenza vaccine and request that the vaccine be given to me or to the person named above for whom I am authorised to make this request.£0.00 for each month Previous Submit Form
