Questionnaire contraceptives

Are you currently using any type of hormonal contraception?

Such as the combined pill, mini-pill, contraceptive ring, an IUS (coil), an implant or a patch.

No Yes

Please provide more details (name, dosage)

Have you ever used contraceptives (oral intake)?

Yes No

Please provide further details. What contraceptives have you taken? Did you have any side effects?

Are you pregnant or have you given birth in the last 6 weeks?

It is not possible to provide a prescription.

Are you currently breastfeeding?

Yes No

Have you given birth within the last 6 weeks?

No Yes

It is not possible to provide a prescription if you are breastfeeding and have given birth in the last 6 weeks.

General health and lifestyle

Do you smoke?

We recommend not smoking while taking the pill or at least reducing your nicotine consumption to less than 15 per day.

Current medications and health status

Have you ever been diagnosed with high blood pressure (Over 140/90)?

No Yes

This medication is not recommended for you because of your high blood pressure. Please check your blood pressure with your doctor or at a pharmacy.

Are you allergic to any substances, medications, ingredients or foods?

No Yes

If yes, please list any medications or substances to which you are allergic.

Are you currently taking medication or have you recently taken medication?

No Yes

Please state the name and dosage of the medication:

Do any of the following statements apply to you?

I had major surgery in the last 3 weeks
I have limited mobility, e.g. Wheelchair users

No Yes

Can you tell us more about it?

Have you or someone in your family suffered from any of the following conditions?

Breast cancer
Cancer of the cervix, uterus or ovaries
Thrombosis (DVT or PE)

No Yes

Please contact your doctor. Our doctors cannot give you a prescription.

Have you ever been diagnosed with any of the following conditions?

Migraines or severe headaches
High cholesterol
Diabetes
Heart attack or stroke
Abnormal vaginal bleeding of unknown cause
Kidney or liver problems
Gallbladder disease

No Yes

Please explain in more detail.

Do you have smear tests done regularly?

If you are over 25, it is important that you get a swab every three years.

Please provide more details

Do you have any other medical conditions we should know about?

e.g. lupus, gallbladder problems, polycystic ovary syndrome, intestinal disorders

Yes No

Please provide more details

I confirm that no contraceptive will 100% protect me against pregnancy.

Yes

Legally effective consent

I confirm that I am over 18 years old and that I use this service voluntarily. The treatment or advice is intended only for me.
I confirm that I have read the entire package leaflet before taking the medication.
I answered all questions truthfully to the best of my knowledge and belief.
I understand that the prescribers accept my answers in good faith and the prescription is based on my answers. False information can be dangerous to my health. I take full responsibility.
I confirm that I will inform my local doctor about this consultation. This is important for further monitoring of my health.
I fully understand the possible side effects of the treatments as well as their effectiveness and alternative options. I would like to continue with my request.

Yes

I agree to the Terms and Conditions and Privacy Policy of Directdoc and – if I choose delivery of the prescribed medication through a partner pharmacy – to the Terms and Conditions and Privacy Policy of the partner pharmacy delivering my order.

I agree to the Terms and Conditions and Privacy Policy of Directdoc and – if I choose to have the prescribed medications delivered through a partner pharmacy – to the Terms and Conditions and Privacy Policy of the partner pharmacy delivering my order. In such a case, I also consent to the partner pharmacy accessing my health data processed through this site to fulfill a prescription and provide pharmaceutical advice. Furthermore, I agree to the transfer of my health data to the cooperating physician treating me and release this physician from their duty of confidentiality to the extent necessary for the execution of my treatment and the delivery of medications. I acknowledge that I have the option to have a prescribed medication delivered by a partner pharmacy of directdoc.eu or to receive the issued prescription by mail. Finally, I agree that non-medical personnel may access my health data to respond to my customer support inquiries. With regard to the transfer of data to customer support, I also release the physician from their duty of confidentiality. I can revoke my consent at any time for the future. I acknowledge that consent is necessary for both treatment and the delivery of prescribed medications. I also agree that directdoc.eu may immediately begin arranging telemedicine services and that the cooperating physician facilitated by directdoc.eu may commence telemedicine services immediately. I acknowledge that my rights to withdraw this consent prematurely expire if the mediation and telemedicine services have been fully provided.

Yes