Emergency Hormonal Contraception

Date

Title*

MissMsMrsDr

Name*

First NameLast Name

Telephone*

Date of Birth*

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Patient Address*

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Patient Address

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Would you like us to send a copy of this consultation to your GP?

NHS Number (if known)

GP Name

GP Address

GP Telephone Number (if known)

Patient's personal details*

Rows	Yes	No
Do you have any recent or past medical history of note?
Do you take any medicines? Antacids? Contraceptives?
Are you currently taking any other medicines? (including any herbal remedies such as St.Johns Wort)
Do you suffer from Bowel disease (e.g. Crohn’s disease) or liver problems?
Do you currently suffer from vomiting or diarrhoea?
Have you ever had a serious reaction to ulipristal acetate (ellaOne) or levonorgestrel (Levonelle)?

Sexual History*

Rows	Yes	No
Have you had unprotected sex within the last 120 hours (5 days)?
Have you had unprotected sex within the last 72 hours (3 days)?
Have you had unprotected sex earlier in this menstrual cycle?
Is there a possibility you may be pregnant?

Sexual History*

Rows	Yes	No
Was your last period late, longer/shorter or unusual in any way?
Have you already taken Levonelle or ellaOne since your last period?

Sexual History*

Rows	Yes	No
Do you understand that if you vomit within 3 hours, another dose is required? You will need to come back or visit your doctor.
Do you understand that If your next period is >3 days late or different in any way you should visit your doctor?
Unprotected sex can lead to sexually transmitted diseases (STIs) do would you like further counseling?

Write below any further information which may be relevant e.g. medicines taking, conditions, concerns...