Emergency Hormonal Contraception Risk Assessment Form
About You
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
NHS No. (if known):
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
GP Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
About our health
Do you have any recent or past medical history of note
*
Yes
No
If Yes, please specify
Do you take any medicines, antacids, contraceptives or any herbal medicines?
*
Yes
No
If Yes, please specify
Do you suffer from Bowel disease (e.g.Crohn’sdisease) or liver problems?
*
Yes
No
If Yes, please specify
Do you currently suffer from vomiting or diarrhoea?
*
Yes
No
If Yes, please specify
Have you ever had a serious reaction to ulipristal acetate (EllaOne) or levonorgestrel (Levonelle)?
*
Yes
No
If Yes, please specify
Have you had unprotected sex within the last 72hours (3days)?
*
Yes
No
Have you had unprotected sex within the last 120hours (5days)?
*
Yes
No
Is there a possibility you may be pregnant?
*
Yes
No
Have you already taken Levonelle or EllaOne since your last period?
*
Yes
No
Acknowledgement
Do you understand that if you vomit within 3 hours, another dose isrequired? You will need to come back or visit your doctor.
*
Yes
No
Do you understand that If your next period is >3 days late or different inany way you should visit your doctor?
*
Yes
No
Do you understand that Unprotected sex can lead to sexually transmitted diseases (STIs)?
*
Yes
No
Submit
Should be Empty: