Medical Assessment

Why do you think you suffer from chlamydia infection?

I was diagnosed by my GP or in a sexual clinic
I had positive home chlamydia test
My sexual partner informed me they were infected by Chlamydia
Other - please specify

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Which of the following symptoms are you suffering from?

do not have any symptoms
pain or burning while peeing
pain during sex
lower belly pain
blood in urine
high fever (above 38°C)
abnormal vaginal discharge (may be yellowish and have a strong smell) – women only
bleeding between periods – women only
pus or a watery/milky discharge from the penis – men only
swollen or tender testicles – men only
pain, discharge and/or bleeding around the anus

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you been treated for Chlamydia in the last 2 months?

Yes No

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you pregnant or breastfeeding or may become pregnant or start breastfeeding whilst taking this medication?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you suffer from any of the following?

Yes No

severe heart problems such as prolonged QT syndrome;
myastenia gravis (type of muscle weakness);
alcohol dependence;
systemic lupus erythematosus (SLE);
liver or kidney problems;
asplenia (absence of normal spleen function);
acute porphyria (blood disorder);
epilepsy or convulsions (seizures);
depression or other psychiatric disorders;
galactose or fructose intolerance;
any other chronic condition that we should know about;

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any of the following medication?

Yes No

anticoagulants such as warfarin;
cisapride (used to treat stomach problems) ;
terfenadine (to treat hay fever);
theophylline (for breathing problems);
digoxin;
any ergot derivatives such as ergotamine (to treat migraine);
cholesterol medication such as atorvastatin or simvastatin;
antiepileptics such as carbamazepine, phenytoin or sodium valproate;
rifampicin, rifabutin (antibiotics);
methotrexate ;
fluconazol, itraconazol;

Please provide the name, dosage and the reason why you are taking that medication or medications.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any other medication not listed above?

Yes No

Please provide the name, dosage and the reason why you are taking that medication or medications.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you allergic to azithromycine, doxycycline, tetracyclines in general or to any of the ingredients in chlamydia medication?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

It is important that you contact your sexual partner(s) to let them know that they may have caught chlamydia. (If you wish to, you can email us their contact information and we would contact them anonymously on your behalf). Do you agree to inform them?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to the following?

Yes No

Not to take any indigestion remedies such as antacids, calcium, iron, aluminium, magnesium and zinc containing medicines at least 2 hours before or after taking chlamydia treatment;
To avoid sunlight and sun lamps while taking doxycycline;
To discontinue the treatment and seek medical help if you start experiencing headache, visual disturbance or any unusual skin reaction;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to the following?

Yes No

If you are currently taking an oral contraceptive pill, you should use at least one other method of protection while taking doxycycline till 7 days after finishing the course;
If you experience vomiting or diarrhoea (caused by doxycycline) it can compromise the contraceptive cover so you should exercise extra caution and seek medical advice.;
you answered truthfully to all the questions and you are aware that any incorrect information you provided might present a danger to your health;
You will seek medical attention if you experience any unusual side effects;
The treatment is solely for your own use to treat chlamydia and no other condition ;
You will read the patient information leaflet supplied with your medication;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

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