Please print this page and present at your local McCabe’s Pharmacy
PATIENT TO COMPLETE and bring into pharmacy
Patient Name: _______________________ Contact Telephone: ____________________
Date of Birth & Age: _______________________
Date: _______________________ Email Address: ______________________ a.
When did the last episode of unprotected intercourse occurred
Date and approx. time _______________ b.
Hours since unprotected intercourse _______________ (if >72hrs refer to doctor) c.
Has there been any other episode of unprotected intercourse since the last period?
Yes / No d.
Did previous period occur more than 4 weeks ago? Yes / No
(If answer to either of two preceding questions is Yes, pregnancy must be excluded before proceeding) e.
Has emergency contraception been used previously in this cycle? Yes / No
(If answer is yes, refer to medical practitioner unless Norlevo has been taken and vomiting occurred within 3 hours) f.
Are you using any other contraceptive method?
(If no, advise on contraceptive options)
Yes / No g.
Are you taking any other medication (including herbal and OTC medication)? Yes / No
Medication being taken:__________________________________________________
_________________________________________________
(If yes, pharmacist must check compatibility of medication with EHC) h.
Have you any history of gynaecological problems such as unexplained vaginal bleeding, ectopic pregnancy or fallopian tube infection? Yes / No i.
Have you had severe liver disease or acute active porphyria? j.
Have you a malabsorption syndrome (e.g. Crohn's or coeliac disease?) k.
Are you hypersensitive to any ingredients of Norlevo?
(Refer if answer to any of previous 3 questions is yes)
PHARMACIST TO COMPLETE DURING THE CONSULTATION
Yes / No
Yes / No
Yes / No
Pharmacist Name & Reg _________________________

Counselling
The following must be communicated clearly to the patient:

EHC is an occasional method of contraception and should not replace a regular contraceptive method

EHC is not guaranteed to prevent pregnancy occurring. If taken with 24 hours of intercourse, it will prevent approximately 95% of pregnancies, 85% if taken at 24-48 hours and 58% if taken at 48-72 hours. For this reason EHC should be taken as soon as possible.

A pregnancy test is recommended if the next period is delayed by more than five days or if the next period is very light or accompanied by unusual pain.

It is recommended to use a barrier method of contraception (e.g. condom) until the next period even if patient is already taking the contraceptive pill

EHC will not protect against sexually transmitted diseases.

EHC can cause side effects including dizziness, headache, nausea, vomiting, diarrhoea, fatigue, irregular bleeding & spotting, headache and breast tenderness.

If vomiting occurs within 3 hours of taking tablet, a repeat dose must be taken as soon as possible. Motilium (if suitable) may help to prevent nausea and vomiting.

If breastfeeding, breastfeeding should be suspended for 8 hours after taking EHC.

Suitable written information (e.g. Norlevo patient information leaflet) should also be given to the patient.
To be signed by patient:
All information given by me is correct to the best of my knowledge. All counselling information above has been given to me by the pharmacist and I am happy that I understand it, including the possibility of failure of this method of contraception. I understand that the responsibility to use this medication correctly, as instructed, lies with me.
Patient signature: ______________________ Date:______________________
Please note:
McCabes Pharmacy respects your right to privacy and will not collect any personal information about you without your clear permission. Any personal information which you volunteer to us will be treated with the highest standard of security and confidentiality, strictly in accordance with the Data Protection Act 1988.