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2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3049 6500
Fax. 020 3049 6515
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Contraception Online Consultation

Please fill out the form below, and one of our doctors will contact you regarding the consultation:

Patient Information

Name: *
Date Of Birth: *
NHS Number (if known):
Address:
Postcode:
Contact Number: *
E-Mail Address: *

Consultation Information

1. Have you read information about contraception on Patient.info?

    It is advised that you read up about contraception.

    Yes

    No

    2. Have you been taking your current pill for a year or more?

      Yes

      No

      3. What is your Body Mass Index

      4. Have you had a smear test in the last 3 years?

        Yes

        No

        5. If you answered Yes to Question 3, do you know the smear result? Please provide:

          6. Are you pregnant?

            Yes

            No

            7. Are you breastfeeding?

              Yes

              No

              8. Are you a smoker?

                Yes

                No

                9. Have you ever suffered from a blood clot? (Deep vein thrombosis, Pulmonary embolism)

                  Yes

                  No

                  10. Has anybody in your family suffered from blood clots, breast cancer, or cervical cancer?

                    Yes

                    No

                    11. Do you suffer from any of the following?

                      Diabetes
                      Migraine Headaches
                      High Blood Pressure
                      Liver Disease
                      Cancer
                      HIV
                      Obesity
                      None Of The Above

                      12. Are you taking any of the following medications?

                        Carbamazepine
                        Griseofulvin
                        Modafinil
                        Nelfinavir
                        Nevirapine
                        Oxcarbazepine
                        Phenytoin
                        Phenobarbital
                        Primidone
                        Ritonavir
                        St Johns Wort
                        Topiramate
                        Rifabutin
                        Rifampicin
                        None Of The Above

                        13. Have you been advised by your doctor or practice nurse to have special monitoring of the pill?

                          Yes

                          No

                          14. Do you suffer from any serious illnesses?

                            15. What are your current medical conditions?

                              16. Do any of the following apply to you?

                                Pregnant
                                Breast Feeding
                                Liver Disease
                                Kidney Disease
                                Asthma
                                Diabetes
                                None Of The Above

                                17. What are your current medications, if any?

                                  18. Do you have any allergies? If so, please list them:

                                    19. Have you considered Long Acting Reversible Contraception?

                                      Yes

                                      No

                                      20. Do you agree to read the leaflet enclosed with your medication?

                                        You must agree to read the leaflet enclosed with your medication

                                        Yes

                                        No