Appendix 1: Pharmacy Client Record for the Community Pharmacy Emergency Hormonal
Contraception Service and Chlamydia Testing Service
Pharmacy Stamp
Client’s Details
Client name/initials (FULL NAME IF
CONSENT GIVEN TO FOLLOW UP
REFERRAL)
Date of consultation
Age/ DoB
Post Code
Contact telephone number for referral to
follow up advice
Date of 1st day of LMP
Length of normal menstrual cycle
Day of cycle of UPSI
Reason for request
Please tick box
UPSI
Missed pill
Condom failure
Vomiting/diarrhoea
Antibiotic/drug therapy
Other (please state)
Please state where client heard about
scheme:
Criteria for Inclusion for EHC
Has client missed her contraceptive pill?
Advice given if missed contraceptive pill?
Since LMP, client has only had unprotected intercourse within the last 72 hour period?
All options for emergency contraception discussed:
 Leaflet
 EHC
 IUCD
Client accepts hormonal method
Criteria for referral (exclusion) for EHC
Client is under 12 years
Client is under 13 years
Yes
No
Yes
No
N/A
Action
EHC cannot be supplied and mandatory
reporting to social services – Child
protection issue
EHC supply for those aged 12 and over
only and mandatory reporting to Social
Services – Child protection issue
Client is under 16 years - Use Fraser Guidelines
Has the client used any other form of emergency
contraception within this cycle?
Was her last period more than 4 weeks ago?
Is the client pregnant or likely to be pregnant?
Was last period abnormal in anyway?
Did UPSI occur more than 72 hours ago?
Does client have known hypersensitivity to
levonorgestrel/excipient?
Is client on any other medication?
Does client have acute severe liver disease?
Does client have acute active porphyria?
Does client have severe malabsorption syndromes?
Refer to social services if concerns
identified
If yes refer, but if Levonelle has been
taken and vomited refer to guidance
If yes, carry out pregnancy test/refer
If yes, refer to Family planning clinic or GP
If yes, refer to Family planning clinic or GP
If yes, refer to Family planning clinic or GP
If yes, refer to Family planning clinic or GP
Check BNF for interactions
If yes, refer to Family planning clinic or GP
If yes, refer to Family planning clinic or GP
If yes, refer to Family planning clinic or GP
Counselling/Actions
Yes
Mode of action and effectiveness including failure rate discussed
Side effects
Possible effects on foetus
Follow up
Condoms issued
Sexual Health advice given
Leaflets given (EHC, Contraception, GUM clinics)
Future contraception discussed
Give leaflet on LARC available
http://guidance.nice.org.uk/CG30/PublicInfo/PrintFriendly/doc/English
Chlamydia discussed including risks of contracting, signs and symptoms
Client is eligible for Chlamydia screening kit
Chlamydia screening kit given out
Referral to Follow up Advice
Action Taken
Supply: Levonelle 1500
Batch number and expiry date
Referral Yes/no
No
(If further advice is required, contact any of the support centres or refer client to any Family Planning Clinic or
GP.)
The above information is correct to the best of my knowledge.
I have been counselled on the use of emergency contraception; Chlamydia and the
screening programme and understand the advice given to me.
On this occasion I accept/decline (please delete as appropriate) the Chlamydia screening kit.
I agree/disagree (please delete as appropriate) to be contacted by the Community and
Sexual Health services three weeks from the date of this consultation.
Clients Signature
Date
The action specified was based on the information given to me by the client, which, to the
best of my knowledge, is correct.
Pharmacists Signature
Date
PLEASE KEEP THIS FORM AT THE PHARMACY AS A RECORD AND FAX THIS
FORM TO C&SH WILLENHALL HEALTH CENTRE, FIELD STREET 01922 604823