Chlamydia

Did you know?
Consumption of Acetazolamide does not serve as substitute for acclimatisation methods unconscious
Whenever acclimatisation techniques are applied, it is not always necessary to use Acetazolamide
Despite taking Acetazolamide, some people still experience altitude sickness including HACE and HAPE
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Yes

No

Are you willing to notify all of your former sexual partners about your diagnosis over the previous six months?
Do you require assistance?

Yes

No

Are you aware of the following:
It is never a good idea to self-diagnose and treat urine incontinence.
At the very least, you should see your doctor for a checkup once a year.
You must follow your doctor's instructions for any treatment.
You should only order repeat supplies of medicines that your doctor has prescribed.

Yes

No

Do yu have a history of using Azithromycin for Chlamydia?
Please select one option
Do you require assistance?

I have never heard of it before

Not more than six months ago

More than six months ago.

Did you experience any side efects after using Azithromycin?

Yes

No

Do you have any reason why you can't take Doxycycline to treat chlamydia?
If you do, what is your reason? It could be you experience allergies

If you dont, do you recognize that the national rules do not allow us to prescribe Azithromycin to you as treatment for chlamydia if you are unable to take Doxycyline which is the authorized medication.

Yes

No

Are you on any of these medications
Migrane medication such as Ergotamine.
Stomach discomfort medication such as Cisapride.
Fever medication such as Terfenadine.
Heart medication such as Sotalol or amiodarone.
Mental health/Bopolar disorder medication such as Amisulpride.
Gout medication such as Colchicine
Arrhythmia medication such as Digoxin
Blood thinner such as Edoxaban
Blood thinners such as Ticagrelor
Cancer medication such as Topotecan
Blood thinners such as Warfarin
Antibiotics such as Ciclosporin.

Yes

No

Are you expeiencing problems such as:
A kind of myasthenia.
A condition in which the body's potassium levels are low.
ventricular cardiac arrhythmia or other heart conditions.

Yes

No

Does any of the following statements apply to you
Azithromycin is a drug to which you are allergic or hypersensitive to.
You've previously used Azithromycin and experienced major adverse effects.
You're taking Azithromycin for a different infection than chlamydia.

Yes

No

What's your gender?

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

No

Does any of these describe you?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

No

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

No

Do yu have a history of using Doxycycline for Chlamydia?
Please select one option
Do you require assistance?

I have never heard of it before

Not more than six months ago

More than six months ago.

Did you experience any side efects after using Doxycycline?

Yes

No

Are you experiencing any of the folowing problems?
A kind of myasthenia.
Porphyria.
Lupus erythematosus.

Yes

No

Are you on any of the following medication?
Antibiotics.
Antihistamines such as stemizole or terfenadine.
Cisapride for stomach discomfort.
Quinidine for circulatory problems.
Pimozide for schizophrenia.

Yes

No

Do you have any of the following signs and symptoms?
Night sweats or a fever.
Urine that contains blood or causes pain when passing.
Sudden weight loss or chest trouble.
Noticeable blood in your stools.
Infection of the urinary tract.
A broad sense of ill health.
Rectal pain or rectal discharge.

Do you require assistance?

Yes

No

Are there any issues about your relationship or sexual partner(s) that you'd like to talk to a healthcare expert about privately?

Yes

No

Did you know that each registered account only secures treatment for one person?
This means, if your sexual partner requires the treatment, they must create an individual account with his/her personal email address and medical information.

Please note that if the same account makes multiple orders they will not be approved and reimbursement will be made.

Yes

No

How are you able to tell if you have chlamydia and need to be treated?
Choose the most suitable option.
Do you require assistance?

After an examination by a certified doctor or a Sexual Health Clinic's diagnosis

You tested positive after a Chlamydia examination

Your sexual partner shared his awareness of the condition with you

You have undergone self examination

Have you ever had an allergic or anaphylactic reaction to doxycycline or any other antibiotics?
If yes, please provide details

Yes

No

Women only: Are you breast feeding?

Yes

No

Do you have any liver problems?
If yes, please provide details

Yes

No

Are you likely to be exposed to strong sunlight or ultraviolet light (e.g. on a sunbed)?

Yes

No

Do you have any kidney problems?
If yes, please provide details

Please provide details in this box here...

Yes

No

Have you had two or more sexual partners in the last 12 months?

Yes

No

Have you had unprotected sex with more than one sexual partner in the last 3 months, or have you been treated for chlamydia in the last 3 months?
If yes, please provide details

Yes

No

Do you have any allergies?
If yes, please provide details

Yes

No

Women only: Are you pregnant or is there a possibility you may be pregnant?

Yes

No

Have you been told by your doctor that you have an intolerance to any sugars?
E.g. fructose intolerance, glucose-galactose malabsorption, or sucrase-isomaltase insufficiency

Yes

No

Do you have any of the following?
Acne
- Itchy skin without inflammation
- Itching around any private parts
- Infected skin
- Flushing of skin on or around your nose (rosacea)
- Spotty red rash around your mouth (perioral dermatitis)

Yes

No

Do you have diarrhoea or do you usually get diarrhoea when you take antibiotics?

Yes

No

Do you have any problems with your stomach or intestines?

Yes

No

Do you have any other recent or past medical history of note?
If yes, please provide details

Yes

No

Please list all your current prescription medication including any medication you buy over the counter...

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