Emergency Contraception Form

Emergency Contraception Questionnaire

Questionnaire: Emergency Contraception

First Name

Surname

Date Of Birth

NHS Number

Address

Address Line 1

Address Line 2

City

Zip Code

Questions:

1. Were there any other episodes of unprotected sex or contraceptive failure since your last normal period? If yes, give the dates and approximate times.

2. Is there a possibility you might be pregnant?

Yes

Not Applicable

3. Do you have any allergies?

Yes

4. Date and approximate time of the most recent unprotected sex or contraceptive failure

5. Please tell us the best times to contact you

6. Are your periods usually regular?

Yes

7. What date did your last normal period start?

8. Was your last period unusual, late, lighter or shorter than usual?

Yes

9. Are you currently taking any medicines, including herbal remedies or supplements?

Yes

10. Please state what contraception was used and what failed, whether you have already used emergency contraception since your last period, your height and weight, whether you are breastfeeding, and any relevant medical conditions (including severe asthma requiring steroid tablets, severe liver disease, Crohn’s disease or another condition affecting absorption).

Consent

15. Are you able to come into the Pharmacy for an appointment?

I confirm the information provided is accurate.

I consent to assessment.

I understand this questionnaire must be reviewed before my appointment request can be accepted.

Mobile Number

GP information sharing consent (optional)

I consent to my GP being informed where appropriate.

Questionnaire: Emergency Contraception

Questions:

Consent

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