1 How do you know you need treatment for Chlamydia? Do any of the below apply to you?
Diagnosed by a home testing kit
Informed by a sexual partner
Diagnosis by a doctor or sexual health clinic
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Please write your explanation in the box below Yes No 2 Have you taken treatment for chlamydia in the last 2 months?
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Please write your explanation in the box below Yes No 3 Are you pregnant or breastfeeding?
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Please write your explanation in the box below Yes No 4 Are you experiencing any of the following?
Fever or night sweats
Blood in your urine or stool
Chest Pain
Unintentional weight loss
Urinary Tract Infection or pain when urinating
Rectal discharge or discomfort
Severe stomach pain
Heavy/Painful periods
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Please write your explanation in the box below Yes No 5 Do you have any of the following conditions?
Heart conditions
Kidney conditions
Liver conditions
HIV
Other medical conditions
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Please write your explanation in the box below Yes No 6 Do you understand that we can only prescribe this medication for the treatment of chlamydia?
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Please write your explanation in the box below Yes No 7 Have you ever been diagnosed with any of the following?
Systemic Lupus Erythematosus or a neuromuscular disease such as Myasthenia granvis
Alcohol dependence
Heart problems
Liver or kidney problems
Porphyria
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Please write your explanation in the box below Yes No 8 Are you allergic to any medicines or other substances?
For instance peanuts or soya.
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Please write your explanation in the box below Yes No 9 It is important that you contact your sexual partner(s) to let them know that they may have caught chlamydia. Please confirm that you understand
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Please write your explanation in the box below Yes No 10
Are you taking any of the following?
Warfarin or any other blood thinners
Antibiotics such as rifampicin
Any medication used to treat epilepsy or seizures such as phenobarbital, carbamazepine, phenytoin or primidone
Any medication used to suppress immunity, such as ciclosporin or methotrexate
Quinapril, used to treat high blood pressure
Ergotamine or methylsergide used to treat migraines
Kaolin, used to treat diarrhoea
Sucralfate, used to treat stomach ulcers
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Please write your explanation in the box below Yes No 11 Do you have any allergies?
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Please write your explanation in the box below Yes No 12 Do you understand that?
You should take this medication as prescribed and complete the course, even if you feel better after a few days
You should inform your recent sexual partners over the last 6 months of your diagnosis. If you are unable to do this, then you should visit your local GUM clinic for “partner notification”
Chlamydia is highly contagious and can be transmitted by vaginal, anal and oral sex. You should read this information leaflet on how to practise safe sex
You should wait at least 7 days after completing the treatment course before engaging in sexual activity
You should test 14 days after completing the treatment course (a full STI test is recommended)
If you are under the age of 25, you should also retest after 3-6 months of completing treatment, and also test regularly for STIs especially if you have more than one sexual partner
You should seek medical advice if symptoms of chlamydia do not disappear after completing the treatment course
Taking medication especially antibiotics, when you do not need them, may increase resistance. This means that they may not work if you need them in the future. You should only proceed if you are certain that you have chlamydia
You should read the Patient Information Leaflet for your own knowledge and for common side effects, and report any side effects and changes in your health and body to your GP, and via the Yellow Card Scheme
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Please write your explanation in the box below Yes No 13 Do you agree to the below?
You will read the Patient Information Leaflet supplied with your medication
You will contact us and inform your GP if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
You are over 18 and the treatment is solely for your own use
You have answered all the above questions accurately and truthfully and that incorrect information can be hazardous to your health
You are aware the decision about your treatment are for both the prescriber and yourself to jointly consider during this consultation, but the final decision will always be the prescriber’s
You will inform your GP that you have ordered this medication
You agree that any treatment prescribed for you is for for your personal use only
By continuing, you agree to our Terms & Conditions and Privacy Policy
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Please write your explanation in the box below Yes No 14 What is the name of your GP surgery and do you consent to us contacting them about your treatment?
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Please write your explanation in the box below 15 Do you consent to us accessing your GP records? This is advised so we can clinically assess suitability.
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Please write your explanation in the box below Yes No 