Contraception

About the Condition and Treatment

To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

Is there a history of jaundice (skin yellowing), liver disease, or liver cancer in your family?

Yes

Has your doctor prescribed desogestrel to you while taking anti-diabetic medicine?

Yes

Do you have diabetes?

Yes

Have you ever been told that you have high or low blood pressure?
This may have been by your GP or another healthcare professional, or by taking your own blood pressure on a home monitor.

Yes

Are you suffering from a blood clot (thrombosis) in your leg or lungs, or any of the symptoms (e.g., acute pain)?

Yes

Could there be a history of breast, uterine, endometrial, or ovarian cancer, or any other hormone-sensitive cancer, or do you fear you do?

Yes

Could you be experiencing any vaginal bleeding that you can't explain?

Yes

Do you suffer from any allergies?
If you do, kindly explain them below

Yes

Have you been advised to avoid strenuous exercise?
If yes, please provide the reason

Yes

Have you or anyone in your family been diagnosed with the following conditions:
- Cancer of the breast, ovary, cervix, or uterus. - Any type of hemorrhage or blood clot (e.g. DVT).- Epilepsy.- Endometriosis.- Varicose veins are a type of varicose veins. Blood pressure that is too high.- The gallbladder or the liver is afflicted.- Fat in the blood is at an all-time high (hyperlipidaemia).- Bleeding from the vaginal area for an unclear reason.- Porphyria or systemic lupus erythematosus.

Yes

Is walking or running difficult for you?

Yes

If you are aware of your blood pressure,how regularly do you visit your doctor to monitor and control it?

Yes

Are you aware of how high or low your blood pressure is?
This could be from an examination by your doctor, a certified medical practitioner or self-examination.

Yes

Do you have any recent or past medical history of note?
If yes, please provide details

Yes

Kindly share your weight and height
Height should be above 1 ft 10 inches

Are you experiencing any of the following health issues?

You've had a heart procedure, a stroke, or a heart attack in the last five years.

You have angina, aortic stenosis, heart failure, cardiomyopathy, high blood pressure that is uncontrolled (greater than 160/90), arrhythmia, or severe heart disease.

You have suffered low blood pressure, fainting, or feeling dizzy when you stand up after lying down in the past.

Diabetes (type I or type 2) or blood sugar levels that are abnormal.

Medical diseases that impact the eyes, such as glaucoma or degenerative eye disease, as well as a family history of these conditions.

Peyronie's disease - a deformity or angulation of the penis.

Sickle cell disease, leukaemia, or multiple myeloma are all examples of blood cancers.

A disease that causes bleeding

Yes

Are you a smoker?

Yes

Do you get migraines on a regular basis?

Yes

Have you noticed anything out of the ordinary regarding your most recent period?

Yes

Are there any issues about your relationship or sexual partner(s) that you'd like to talk to a healthcare expert about privately?

Yes

For which duration have you used hormonal contraception (pill or patch) in total?

Were you ever warned not to take hormonal contraception (pills or patches) or are you aware of any reason why you shouldn't?

Yes

In the recent three years, have you undergone a cervical screening (smear) test?
If not, could you kindly explain why a smear test was not performed?

Yes

Are you aware of the following:
It is never a good idea to self-diagnose and treat urine incontinence.
At the very least, you should see your doctor for a checkup once a year.
You must follow your doctor's instructions for any treatment.
You should only order repeat supplies of medicines that your doctor has prescribed.

Yes

Is your doctor now prescribing Brevinor tablets to you?

Yes

Did you know that:
A healthcare practitioner should assess any acute injuries.
You should see your doctor about chronic pain at least once a year.

Yes

Is your doctor now prescribing Desogestrel 75mcg Tablets to you?

Yes

Is your doctor now prescribing Cilique Pill to you?

Yes

Is your doctor now prescribing Cerelleto to you?

Yes

Is your doctor now prescribing Cerazette Tablet to you?

Yes

Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Yes

Can you relate to any of the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

What is your biological gender?
Please select your option

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

Can you relate to any of the following statements?
You have or have had stomach or duodenal ulcers, as well as stomach or intestinal bleeding in the past.
Your doctor has ever told you that your kidney function is less than 100 percent.
You have previously suffered a terrible reaction to aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs).
You want to use Ibuprofen Gel on skin that is fractured, injured, diseased, or infected.

Yes

Are you on any of the following medications?
Fluvoxamine
Benzodiazepines
Antidepressants of any kind
Any sleep-inducing medication
Do you require assistance?

Yes

Do you remember the last time you had a pill check with your doctor? Please include the month and year in your response.

About the Medicine

Do you agree to the following?

You will read the patient information leaflet supplied with your medication.

You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.

The treatment is solely for your own use.

You have answered all the above questions accurately and truthfully.

You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes

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