Yasmin pill Form General Health QuestionsThe information you provide us is treated with the utmost confidentiality and will be reviewed by a registered doctor. The questions listed are to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not. Are you registered with a GP practice in the UK?(Required) Yes No Why are you not registered with a GP practice?(Required)Do you give us consent to write to your GP to share information of this supply and any information we hold about you? Yes No Please enter the name of your GP practice.(Required)Do you believe you have the capacity to make decisions about your own healthcare?(Required) Yes No Unfortunately, we cannot recommend a suitable treatment for you. If you did this in error, you have the choice to change your answer. If you have any questions about this consultation, please email [email protected]. Have you been diagnosed with any medical conditions?(Required) Yes No Please provide more information, including diagnosis, symptoms and treatment.(Required)Have you ever been diagnosed with a mental health condition?(Required) Yes No Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.(Required) Yes No Do you suffer from any allergies?(Required) Yes No Is there anything else you would like to include for the prescriber?(Required) Yes No What is your blood pressure?(Required)What is your weigh?(Required) What is your blood pressure?(Required) Low (below 90/60) Low (below 90/60) Normal (between 90/60 and 140/90) High (above 140/90) What was the date of your last blood pressure check?(Required)Are you currently using any kind of contraception (pill, ring, patch or other)?(Required) Yes No Do you ever have vaginal bleeding even when you are not on your period?(Required) Yes No Do you smoke?(Required) Yes No Have you ever been told by a doctor that you have abnormal cholesterol?(Required) Yes No Have you or anyone in your family ever had a blood clot?(Required) Yes No Have you had any major surgery in the last 3 weeks?(Required) Yes No Do you have a history of migraines?(Required) Yes No Do you agree to the following?(Required)Do you agree to the following? Nothing has changed with my general health since my last order (if applicable). I agree to ordering the lowest strength, if this is the first time I am taking this medication. I confirm I am over 18 years old. The medicine being requested is for my use only. I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages. I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances. I have answered all the questions truthfully. I understand my request still needs to be reviewed and approved by the prescriber, until they approve, my request is not guaranteed at this stage. I confirm I have the capacity to make decisions about my own health. I agree to Dr Newton’s terms and conditions. Yes No
