Bacterial vaginosis

Are you seeking treatment for a vaginal infection?

Are you aged 18-55?

Have you been treated for bacterial vaginosis before?

Have you been treated for bacterial vaginosis more than three times in the last 12 months?

Do you have thin, white or watery/grey vaginal discharge with a fish-like odour?

Do you have any of the following symptoms along with your discharge?

• Itching
• Soreness
• Irritation

Is there any chance you may still be wearing a tampon from your last period?

Do you have a fever, shivers, lower abdominal pain or abnormal vaginal bleeding?

Are you pregnant or breastfeeding?

In the last six weeks, have you given birth, had a miscarriage or a termination of pregnancy?

In the last two months, have you had any gynaecological procedures, for example colposcopy, cautery to the neck of the womb, a repair of a prolapse, or any other operation?

Do you have any of the following?

• Liver disease
• Kidney disease
• A history of Stevens Johnson Syndrome
• A history of Toxic Epidemal Necrolysis
• Cockayne Syndrome
• Inflammatory Bowel Disease or a history of antibiotic associated colitis
• Any neurological disease e.g peripheral neuropathy, multiple sclerosis, MND, ataxia

Do you have an allergy to metronidazole or clindamycin?

Are you taking any of the following medication?

• Antibiotics
• Anticoagulants acenocumarol or warfarin
• Alcohol
• Amiodarone
• Busulfan
• Capecitabine
• Ciclosporin
• Disulfiram
• Fluorouracil
• Lithium
• Phenobarbitol
• Phenytoin
• Primidone

I understand I should speak to my GP if my symptoms do not settle after treatment, or if I develop any further symptoms during treatment.

I understand that I should seek urgent medical advice if I feel unwell or develop a fever, shivers or rigors during treatment.

I understand that if I receive metronidazole for the treatment of bacterial vaginosis, I should not consume alcohol during and 2 days after my treatment.

I understand if I receive intravaginal clindamycin, it may make condoms and diaphragms less effective.

I understand if I receive intravaginal clindamycin, I will stop using it and seek medical advice if I develop diarrhoea.

Do you agree to the following?

• You will read the patient information leaflet supplied with your medication
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
• The treatment is solely for your own use
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.