Treatment Questions – Your Chemists

Are you over 18 and under 65?

Yes No

Were you assigned female gender at birth?

Yes No

Have you been diagnosed with yeast infection in the past?

Yes No

Have you had more than 2 episodes of thrush in the past 6 months?

Yes No

Have you ever had an allergic reaction to fluconazole?

Yes No

Have you had any bleeding outside of your normal cycle or after sex or have you developed any sores, blisters or ulcers in or around your vagina?

Yes No

Are you currently pregnant?

Yes No

Have you got poorly functioning kidneys or are you currently receiving treatment for kidney disease?

Yes No

Have you been advised that you have a prolonged QT interval on an ECG?

Yes No

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes No

Are you taking any of the following medications?

Yes No

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.

Yes No

Thrush