Emergency Hormonal Contraceptive

Patient's personal details

Do you have any recent or past medical history of note? *

Reconfirm details at each appointment. *

Do you take any medicines? Antacids? Contraceptives? *

Reconfirm details at each appointment. *

Are you currently taking any other medicines? (including any herbal remedies such as St.Johns Wort) *

Reconfirm details at each appointment. *

Do you suffer from Bowel disease (e.g. Crohn’s disease) or liver problems? *

Reconfirm details at each appointment. *

Do you currently suffer from vomiting or diarrhoea? *

Reconfirm details at each appointment. *

Have you ever had a serious reaction to ulipristal acetate (ellaOne) or levonorgestrel (Levonelle)? *

Reconfirm details at each appointment. *

Sexual History

Have you had unprotected sex within the last 120 hours (5 days)? *

Reconfirm details at each appointment. *

Have you had unprotected sex within the last 72 hours (3 days)? *

Reconfirm details at each appointment. *

Have you had unprotected sex earlier in this menstrual cycle? *

Reconfirm details at each appointment. *

Is there a possibility you may be pregnant? *

Reconfirm details at each appointment. *

Your last menstrual period...

Was your last period late, longer/shorter or unusual in any way? *

Reconfirm details at each appointment. *

Have you already taken Levonelle or ellaOne since your last period? *

Reconfirm details at each appointment. *

Further information about ulipristal acetate (ellaOne)...

Do you understand that if you vomit within 3 hours, another dose is required? You will need to come back or visit your doctor. *

Reconfirm details at each appointment. *

Do you understand that If your next period is >3 days late or different in any way you should visit your doctor? *

Reconfirm details at each appointment. *

Unprotected sex can lead to sexually transmitted diseases (STIs) do would you like further counselling? *

Reconfirm details at each appointment. *

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

Patient's Personal Details

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NHS No. (If Known)

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£666.00

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Emergency Hormonal Contraceptive

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