Questionnaire | Chemist Click UK

1

Do you believe you have the capacity to make decisions about your own health; and that you do not require help to complete this consultation?*

2

Do you have any concerns about your relationship or sexual partner(s) that you wish to discuss privately with a healthcare professional?*

3

What is your height?*

cm*

4

What is your weight?*

kg*

5

Current UK guidelines recommend referral to a genito-urinary medicine (gum) clinic for the management of chlamydia. Please let us know the reason you are unable to / do not want to visit a gum clinic?*

I have not got the time

I feel embarrassed

Other

6

Do you understand that we can only prescribe medication for the treatment of chlamydia?*

Our listed treatments do not treat all STIs. If you think you need antibiotics for another condition, you should visit your GP or call 111 for advice.

7

Do you understand that we can only provide treatment for one person per account?*

If your partner requires treatment, they will need to register their own account with their own e-mail address and medical information. Multiple orders from the same account will be cancelled and refunded.

8

Do you understand that azithromycin is not the recommended first line treatment for chlamydia and there is a possibility it may not work?*

Doxycycline is the first-line treatment for chlamydia. Azithromycin was used previously for the treatment of chlamydia. Due to antibiotic resistance, it is now no longer the recommended treatment for chlamydia due to its reduced effectiveness. If you have tested positive after taking a course of antibiotics, you should visit a sexual health clinic.

9

How do you know that you need treatment for chlamydia?*

If you are experiencing symptoms of chlamydia but have not been diagnosed, had a positive test, or been informed by a sexual partner, you should not order treatment. You should have yourself checked, as STIs can display similar symptoms. Taking the wrong treatment can delay you receiving the correct treatment, as well as contribute to antibiotic resistance. You can order a chlamydia test kit online, or visit your local GUM clinic.

Diagnosed by a doctor or sexual health clinic

Positive chlamydia test

Informed by a sexual partner

Reinfected due to sexual contact within a week of completing treatment

Other

10

Have you already taken antibiotics to treat the current chlamydia infection?*

11

Have you recently (within the last three months) finished a course of antibiotics?*

12

Have you taken treatment for chlamydia before?*

13

Are you pregnant, breastfeeding, planning pregnancy or at risk of pregnancy whilst taking this medication?*

Pregnancy risk may be defined as a late period or unprotected sexual intercourse which may have taken place since your last normal period.

14

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
Unusual vaginal discharge (especially if unusually yellow or green)
Nausea and vomiting
Pain in your joints

15

Have you ever been diagnosed with any of the following?*

Systemic Lupus Erythematosus or a neuromuscular disease such as Myasthenia gravis
Alcohol dependence
Heart problems
Liver or kidney problems
Porphyria
Low potassium or magnesium levels
Malabsorption, or sucrase isomaltase insufficiency
Problems with your nervous system
Psychiatric problems

16

Do you have any other medical conditions?*

17

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

18

Are you taking any other medication, or have you recently finished a course of medication?*

19

Do you have any allergies?*

20

Do you understand that you should stop taking chlamydia treatment if you experience:*

Diarrhoea
A ringing or buzzing noise in the ear
Skin reactions
Signs of an allergic reaction, such as wheeziness, difficulty breathing, chest pain, fever, swelling of the face, lips, tongue, throat, hands or feet
Fever, swollen lymph nodes or a rash
Sickness
Problems with your hearing
Yellowing of the skin
Severe stomach or back pain
Changed to your urine habits
Bruising or bleeding that is unusual
Irregular heartbeat
Any other side effects that are unusual

Whilst you should seek urgent medical advice, you should also inform your GP and inform us if you experience any of the above. You should call 999 in the case of a medical emergency, or 111 for advice.

21

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
Doxycycline can increase sensitivity to sunlight. You should take precautions, such as limiting your exposure to sunlight and using sunscreen
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

22

Is there any additional information you would like to provide, or any questions you have?*

23

Do you confirm that?*

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
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