Chlamydia - MedPro Pharmacy & Clinic

About your condition and treatment

To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

Which of the following symptoms are you suffering from?

Do not have any symptoms

Pain or burning while urinating

Pain during sex

Pain in tummy or pelvis

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

Why do you think you suffer from chlamydia infection?

I was diagnosed by my GP or in a sexual health clinic

I had positive home chlamydia test

My sexual partner informed me they were infected by Chlamydia

Other - please specify

If your pervious question answer is other, please provide the information here, otherwise please type in N/A.

About your health

Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

Are you pregnant, planning to become pregnant or breastfeeding?

Yes

Do you take any current or repeat medicines of the following medication?

- Verapamil

- Diltiazem

- Rizatriptan

- Any inhalers

- Any medication for blood pressure

- Warfarin

- Digoxin

- Disopyramide

- Amiodarone

- Calcium Channel Blockers

- Beta Blockers

- Ergotamine or dihydroergotamine

- Chlorpromazine

- Quinidine

- Propafenone

- Rifampicin

- Theophylline

- Thioridazine

Yes

Do you suffer from any allergies?
If you do, kindly explain them below

Yes

Do you suffer with any of the following?

- Severe heart problems such as prolonged QT syndrome.

- Myasthenia gravis (type of muscle weakness).

- Alcohol dependence.

- Systemic lupus erythematosus (SLE).

- Severe liver or kidney problems.

- Asplenia (absence of normal spleen function).

- Acute porphyria (blood disorder).

- Have diarrhoea or usually get diarrhoea when you take antibiotics or have suffered from problems with your stomach or intestines.

- Your blood levels of potassium or magnesium are too low.

Yes

Do you take any of the following medicines?

- Rifampicin (to treat TB), Rifabutin (antibiotics).

- Anticoagulants (e.g. warfarin - to thin the blood).

- Quinapril (to treat high blood pressure).

- Kaolin (to treat diarrhoea), cisapride (used to treat stomach problems)

- Barbiturates (e.g. phenobarbital - to treat sleeping problems).

- Ergotamine or Methylsergide (to treat migraines).

- Epilepsy treatments (such as carbamazepine and phenytoin).

- Methotrexate, ciclosporin, hydroxychloroquine or chloroquine

- Retinoids (to treat skin conditions).

- Terfenadine (to treat hay fever).

- Theophylline (for breathing problems).

- Digoxin.

- Fluconazole, itraconazole.

- HIV treatment - zidovudine or nelfinavir

Yes

Acknowlegdements

Are you aware you should refrain from sexual contact for 7 days after taking treatment, until no longer infectious.You should also inform any sexual partner(s) of your chlamydia treatment ?

Yes

Are you aware treatment may take up to 14 days to clear your symptoms?

- Retesting is recommended if symptoms persist past 14 days.

- Retesting after 6 months is recommended if under 25.

Yes

Do you understand that:

- Chlamydia is highly contagious and can be transmitted by having sex (vaginal, anal, or oral).

- It is important to prevent the spread of chlamydia by avoiding sex until 7 days after all symptoms have cleared up and continuing to use a condom afterward.

- We recommend that you have a full STI test 14 days after treatment to confirm it has been effective and that you are not suffering from any other STIs.

- We highly recommend you inform all your previous sexual partners in the last 6 months of your diagnosis

- Treatment may make the oral contraceptive pill less effective. You should use additional contraceptive precautions whilst taking this medicine and for 7 days after stopping.

Yes

Can we share this information with your General practitioner?

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Yes

Do you agree to the following ?

- The treatment is solely for your own use.

- You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health.

- You will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.

- You will inform your doctor about any unusaul side effects.

Yes

Chlamydia (MedPro)

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