Morning After Pill (EHC) Assessment Form – Walk IN

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Step 1 of 2
Name
Do you have any recent or past medical history of note?
Are you currently taking any medicines including any herbal remedies? (e.g. St John's Wort)
Do you have any liver problems?
Have you had a serious reaction to levonorgestrel (Levonelle)?
Have you previously had an ectopic pregnancy, gestational trophoblastic tumours or salpingitis?
Have you had unprotected sex within the last 72 hours (3 days)?
Have you had unprotected sex earlier in this menstrual cycle?
Was your last period late, longer/shorter or unusual in any way?
Do you understand that if you vomit within 3 hours, another dose is required?
You will need to come back or visit your doctor.
Have you already taken Emergency Hormonal Contraception, such as levonorgestrel (Levonelle) or ulipristal acetate (ellaOne) since your last period?
Do you understand that If your next period is >5 days late or different in any way you should visit your doctor?
Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Are you breast-feeding?
Do you have any allergies?
Do you understand that If your next period is >5 days late or different in any way you should visit your doctor?
Are you aware that the use of emergency contraception does not replace the necessary precautions against sexually transmitted diseases?
Please speak to your pharmacist if you require further counselling
Do you have porphyria?
Do you suffer from malabsorption syndromes, bowel disease (e.g. Crohn’s disease), vomiting or diarrhoea?
Have you been told by your doctor you have an intolerance to any sugars (e.g galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)?
Do you have severe asthma?
Are you currently using contraception?

Start Assessment

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Step 1 of 3
Patient Name
Parent or guardian name if applicable
Have you had a serious reaction to any acne treatments before?
Do you have any allergies?
Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant? (copy)
Are you breast feeding?
Have you started puberty?
Are you willing to use contraception for at least 1 month before starting treatment, during treatment, and for at least 1 month after stopping treatment?
Do you have perioral dermatitis (redness and soreness around your mouth) or rosacea?
Are you currently using any other treatments for acne?
Have you recently received an acne treatment containing antibiotics?
If you have used acne treatments before, did you experience any side effects or skin irritation?