Azithromycin

A prescriber reads every answer. Answer honestly: a wrong answer here is not a shortcut, it is the thing that makes a medicine unsafe for you.

1About your health
2About this treatment
3About you

Allergies

Do you have any allergies to medicines? * Yes No I am not sure

Which medicines, and what happened? *

Current Medications

List any medicines you take, including anything you buy without a prescription. *

Medical History

Are you being treated for any long-term condition? * Yes No

Which conditions? *

Have you or a sexual partner of yours had a postiive chlamydia test? * Yes No

If yes when were you tested? *

Have you taken treatment to treat chlamydia before? * Yes No

When did you last take antibiotics for Chlamydia? *

Did you suffer from any side effects? *

Are you aware Chlamydia treatment does not treat all sexually transmitted disease? * Yes

Are you experiencing frequent or recurrent Chlamydial infections? * Yes No

Have you or a sexual partner of yours had a positive chlamydia test? * Yes No

Are you aware you should refrain from sexual contact for 7 days after treatment has been completed, until no longer infectious? * Yes

Have you been tested for Chlamydia? * Yes No

When were you tested? *

Have you been tested for any other STIs? *

Do you take warfarin or any other blood thinning treatment? * Yes No

Do you take isotretinoin (Roaccutane) or any other retinoid treatment? * Yes No

Current Medications

Are you taking any of the following treatment?Antacids containing aluminium or magnesium / Warfarin or other anticoagulants / Ciclosporin / Digoxin / Ergotamine or dihydroergotamine / Nelfinavir / Other antibiotics / Any medicines known to prolong the QT interval, such as antiarrhythmics, antipsychotics, or antidepressants * Yes No

Are you taking any of the following treatment?AcenocoumarolAcitretinAlitretinoinCiclosporinIsotretinoinLithiumPhenindioneTretinoin (tablets)Warfarin" * Yes No

Allergies

Are you allergic to any antibiotics? * Yes No

Which antibiotics are you allergic to? (Please list these clearly) *

Can you confirm you understand the following essential safety advice for Doxycycline?Take doxycycline exactly as prescribed and complete the course unless told otherwise.Swallow with plenty of water while sitting or standing, and do not lie down for at least 30 minutes afterwards to reduce throat/oesophageal irritation.Doxycycline can make your skin more sensitive to sunlight. Use high-factor sun protection, cover exposed skin, avoid strong sunlight where possible and do not use sunbeds during treatment.Do not take it at the same time as antacids, indigestion remedies, iron, zinc, calcium or magnesium supplements; separate these by several hours as they can reduce absorption.Stop and seek urgent advice if you develop severe headache/visual disturbance, severe diarrhoea, allergic swelling/wheeze, or a widespread blistering rash.I am aware I should refrain from sexual contact for 7 days until my treatment has been completedI am aware that after treatment, it may take up to 14 days for symptoms to goWhere possible, sexual partner(s) should be informed of my need for chlamydia treatmentI am aware aware that guidelines recommend a repeat chlamydia test after 3 months if you are under 25 years old?I will, read the patient information leaflet, contact us and inform your GP of any side effects or changes in treatment or health conditions. I can confirm treatment is solely for your own use * Yes No

Your answers are seen by the prescriber reviewing your order and the dispensing pharmacist. They are not used for marketing.

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