To be completed by the patient. Private and confidential.
Answer as many questions as possible by ticking the boxes. If you get stuck on a question, leave it blank and ask
the pharmacist to help you.
1/ Are you over 16?  YES  NO
Pharmacists are not allowed to sell morning after pill to women under 16. But it is possible to all women to be
prescribed the pill on the prescription under medical supervision from a doctor.
2/ Is Escapelle/Postinor-2 for your own use?  YES  NO
3/ Have you had unprotected sex within the last 72 hours (3 days)?  YES  NO
4/ Have you had unprotected sex earlier in this cycle?  YES  NO
5/ Was your last period late, lighter/shorter or unusual in any way?  YES  NO
6/ Have you already used Escapelle/Postinor-2 since your last period?  YES  NO
7/ Are you currently taking any other medicines, including herbal remedies (e. g. St. John’s wort)?
 YES  NO
Please write down the name(s) of any medicines you are currently taking
………………………………………………………………………………………………………………………………………………………………………..
8/ Do you suffer from bowel disease (e.g. Crohn’s disease) or liver problems?  YES  NO
9/ Have you ever had a disease called salpingitis (inflammation of the Fallopian tubes)? Have you ever had an
ectopic pregnancy (where the baby develops somewhere outside the womb)?  YES  NO
10/ Have you ever had an allergy to levonorgestrel (a hormone commonly used in the combined contraceptive
pill)?  YES  NO
11/ Have you ever had an allergy to lactose?  YES  NO
Always read the in-pack leaflet. Ask your pharmacist for further information.