Medical Questions

Have you used this contraceptive before?

What is your blood pressure?

Have your periods been regular?

Have you missed any pills in the last 2 months? 

Have you experienced any side effects from using this contraceptive?

Have you had your blood pressure checked in the last 12 months?

Are you experiencing abnormal vaginal bleeding of unknown cause?

Have you had a baby in the last 6 weeks?

Are you attempting to become pregnant or are you currently pregnant or breastfeeding? 

Have you ever suffered from any of the following:

• Migraines or severe headaches?
• Crohn’s disease or ulcerative colitis?
• High cholesterol or diabetes?

Have you or anyone in your family ever suffered from any of the following:

• Breast Cancer
• Stroke
• Cancers of the cervix, ovary or uterus
• Heart attack
• Thrombosis (DVT or PE)

Have you ever been advised to not use any form of hormonal contraceptive?

Are you aware of and do you understand the following:

• All forms of contraception is NOT 100% effective and Cloud Pharmacy (Pharmarx ltd.) is not responsible if the contraceptive fails.
• This product should only be used if you are NOT pregnant.
• You should use barrier contraceptives (condoms) or not have sex until the your contraceptive becomes effective. 
• Having unprotected sex puts you at risk of sexuall transmitted infections and that it is important to get tested, especially if you have a new partner or have had more than one sexual partner in the last 12 months. Oral contraception does not protect you from contracting sexuall transmitted infections. 

Do you have any allergies?

Do have have any kidney or liver problems?

Do you drink alcohol?

Do you smoke?

Other than any medicines previously mentioned, do you take any other prescription or over-the-counter medicines or recreational drugs?

Have you ever had any other medication conditions, have you had any surgery or do you think there is anything else we should know?

You understand that we will inform your GP of your purchase/prescription from our doctors so that your own doctor can continue to monitor and look after your health to provide safe and effective ongoing care unless you object to us sharing your information. Do you consent for this information to be shared with your GP?

I agree to read the patient information leaflet before taking any medication and use only as directed.