Emergency Hormonal Contraception (EHC) - Questionnaire

EHC - "The Morning After Pill" - can be provided FREE of charge to all women of child-bearing age up to 72 hours (3 days) after unprotected sex. The EHC we provide is levonorgestrel. We are required to ensure that EHC is both necessary and appropriate for you. By completing this quick questionnaire, we can save you time and ensure your privacy if you need to come to the pharmacy.

If more than 72 hours (3 days) have elapsed since you had unprotected sex, please complete the questionnaire and we will email information on alternative options that are available to you.

See our Emergency Hormonal Contraception page for full information.

Your Details

Why we need this information - find out more.

We will use your e-mail address to send you a unique reference code that you can quote when you arrive at the pharmacy. Our staff will recognise this code so your request can be dealt with without you having to disclose the purpose of your visit.

We will use your mobile number to send your code via SMS (if chosen). Additionally, based on your answers, it may be necessary for our Pharmacist to call you to discuss your EHC options. For example, missing contraceptive pills does not necessarily mean you will need EHC.

Receive a unique reference code by SMS?

By checking this box, I confirm that I have answered all questions to the best of my ability and that this request for EHC is for my own personal use.

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Why do we need to collect this information?

Date of birth

The EHC service allows us to provide emergency contraception of all women of child bearing age. There are special arrangements in place for children under 13. By collecting your age in advance, we can decide on the appropriate treatment option.

Postcode area

This data is required to be collected by the commissioner of the service, Public Health Portsmouth.

Email address

We use your email address to:

  • Send a copy of your answers, along with advice tailored to the answers you have provided.
  • Send your unique code. This will allow you to access the service in the Pharmacy without identifying the reason for your visit. It also allows you to call and speak to our pharmacist in strict confidence.
Mobile number

We use your mobile number to:

  • Allow our pharmacist to call you to discuss your request before you travel to the Pharmacy. For example, if you have missed some contraceptive tablets, emergency contraception may not be required. We can advise you accordingly and save you an unnecessary trip to the Pharmacy.
  • (Optionally) send you your unique code via SMS
Reason for request

As mentioned above, emergency contraception may not be necessary in all circumstances. Based on your answers, the pharmacist may advise you that there is no need for treatment.

How long ago unprotected sex took place

We can only provide emergency contraception free of charge up to 72 hours (3 days) after unprotected sex. There are other options available from 72 to 120 hours (3 - 5 days) after unprotected sex and there is a possibility of alternate treatment in some cases after 120 hours (5 days). Collecting this information allows our pharmacist to provide you with the correct treatment or refer you for alternative treatment.

Could you be pregnant already

The pharmacist will need this information to choose the appropriate course of action in the event you believe you might already be pregnant.

Please note: all information is handled in strict confidence in accordance with data protection laws and the NHS Code of Confidentiality.

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