• History
  • Medicines
Our doctors would now like to check your suitability for this product

How did you hear about us?

Your reproductive health

Have you ever been diagnosed with HPV, genital warts, or a cancer of the cervix, vulva, vagina or anus?

Have you ever received any HPV vaccinations before?


Your medical history

Do you have a bleeding or clotting disorder?

Do you have a condition that suppresses your immune system? Examples include: HIV, cancer, organ transplant, and not having a spleen that works

Other than those already mentioned, do you have any other significant medical conditions, illnesses or past surgical procedures?

At present are you suffering from a cold, viral infection, fever, wheeze, breathing difficulties or are you feeling unwell?

Are you pregnant, or planning to become pregnant in the next 6 months?


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

Current and recent use of medicines

In the past 6 months, have you had: Steroid tablets Medication that affects your immune system Chemotherapy Radiotherapy

Other than those already mentioned, are you taking any medication?


Allergies

Are you allergic to any of the following? Please select all that apply.

Do you have any other known allergies?

Have you ever had a reaction to an injection or vaccine?


0% of questionnaire complete