1
Your Health
The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.

What is your gender?

Are you currently pregnant or breastfeeding?

NoYes

Please provide more detail.

Do you need help completing this questionnaire?

NoYes

Please contact us on 020 7157 9759 or email [email protected] and we can assist you.

Do you believe that you have the capacity to make decisions about your own healthcare?

NoYes

Sorry we can't offer you this treatment, please contact your GP.

Have you been diagnosed with any medical conditions?

NoYes

Please provide more detail.

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.

NoYes

Please provide more detail.

Do you suffer from any allergies?

NoYes

Please provide details including which allergies and what symptoms you experience.

Is there anything else you would like to include to allow our prescriber to prescribe responsibly?

NoYes

Please provide more detail.

2
Medical Questions

Why do you need treatment for Bacterial Vaginosis (BV)?

Please provide more information below.

e.g: online research via websites such as WebMD or at-home test kit

Which of the following symptoms are you experiencing?

You can select more than one

Are you suffering from abdominal pain?

If the pain is moderate or severe can you please tell us more.

For example:

have you needed to take pain killers to control the abdominal pain?
is the pain affecting your ability to complete daily tasks or stopping you from going to work?
is the pain vastly different from what you normally experience?
has the pain made you vomit?

If the pain is moderate or severe can you please tell us more.

For example:

have you needed to take pain killers to control the abdominal pain?
is the pain affecting your ability to complete daily tasks or stopping you from going to work?
is the pain vastly different from what you normally experience?
has the pain made you vomit?

Do you have abnormal vaginal bleeding?

If you have frequent or heavy bleeding between periods, please tell us more so that we can advise.

For example:

how long has this been an issue?
could this be due to period coming?
have you seen a doctor about this and what have they advised?
did the bleeding start when you started to experience bacterial vaginosis (BV) symptoms or was it a problem before the BV symptoms started?

If you have frequent or heavy bleeding between periods, please tell us more so that we can advise.

For example:

how long has this been an issue?
could this be due to period coming?
have you seen a doctor about this and what have they advised?
did the bleeding start when you started to experience bacterial vaginosis (BV) symptoms or was it a problem before the BV symptoms started?

Have you suffered from more than FOUR cases of BV in the last 12 months?

NoYes

Please provide us with more informatin about your condition so that we may be able to help you.

For example:

what is the reason for your repeated infections?
have you seen your GP to investigate the cause of your repeated infections? If you have, please teel us what they said

Do you have an IUD (Intra-uterine device) fitted?

An IUD is used for contraception.

NoYes

Please provide more information, such as which IUD you have had fitted and for how long

Do either of the following apply:

you currently have an STI
you have had unprotected sex with a new partner in the last 2 months

NoYes

If you have had unprotected sex with a new partner within the last 2 months, have you had an STI test to rule out symptoms being caused by an STI?

NoYes

Could your symptoms be caused by a tampon that has been retained?

A retained tampon could also cause unpleasant smelling discharge.

NoYes

Please provide more information

Do you agree to see your doctor if:

you suspect you may have an STI
your symptoms worsen or they do not get better after treatment
you are pregnant
you are experiencing signs of pelvic inflammatory disease (discomfort during sex felt deep inside the pelvis, pain around the pelvis or lower abdomen, bleeding between periods and after sex)

Confirm

Have you successfully used this treatment to treat Bacterial Vaginosis in the past?

NoYes

Do you take any of the following medicines:

Disulfiram (for alcoholism)
Cimetidine (for stomach problems)
Ciclosporin (for organ rejection)
Anti-coagulants (blood thinning agents such as Warfarin)
Lithium
Medicines used to treat epilepsy (phenytoin, primidone or phenobarbiton)
Busulfan (for leukaemia)
5-fluorouracil (for cancer)

NoYes

Please provide more information

Have you had any gynaecological examinations or procedures recently?

NoYes

Please provide more information

3
Consent

Would you like us to notify your GP of the treatment you chose to order today?

NoYes

Please provide details.

Doctor Surgeries

[% doctor_surgery.practice_name %]

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I can't find my surgery and would like to edit the address below.

Please enter your GP details below

It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.

Do you agree to the following:

You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You are aware you will be subject to a soft check to validate your identity via LexisNexis
You will read the Patient Information Leaflet supplied with your medication
You agree to Cloud Pharmacy terms and conditions and privacy policy.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You will inform your GP of this purchase if appropriate

NoYes

Sorry we can't offer you this treatment, please contact your GP.

If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Assessment

Trust Pilot

Medical Questions

2
Medical Questions

3
Consent

Doctor Surgeries

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Confirm treatment selection

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Information

Customer care

External Links

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Assessment

Trust Pilot

Medical Questions

2Medical Questions

3Consent

Doctor Surgeries

No Results found

Searching

Confirm treatment selection

2
Medical Questions

3
Consent