Are you aged over 18?

Have you or a sexual partner of yours had a positive chlamydia test?

Do you have any of the following?

Mucous from the back passage blood coming from the penis bad smelling vaginal mucous vaginal bleeding not due to your period? Severe pelvic pain and / or a temperature?

Are you taking any of the following medicines?

Acenocoumarol Acitretin Alitretinoin Ciclosporin Isotretinoin Lithium Phenindione Tretinoin (tablets) Warfarin

Are you aware you should refrain from sexual contact for 7 days until your treatment has been completed?

Are you aware, after treatment, it may take up to 14 days for symptoms to go? (You may have no symptoms at all)

Are you aware doxycycline does not treat all sexually transmitted disease?

Are you aware, where possible, sexual partner(s) should be informed of your need for chlamydia treatment?

Are you aware that guidelines recommend a repeat chlamydia test after 3 months if you are under 25 years old?

Do you agree to the following?

You will read the patient information leaflet supplied with your medication You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment. The treatment is solely for your own use You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Are you pregnant, breastfeeding or planning to become pregnant whilst taking doxycycline?

Do you have any of the following conditions?

Kidney problems Liver problems Heart problems Systemic Lupus Erythematous Myasthenia Gravis Alcohol dependency Benign Intracranial Hypertension

Are you allergic to doxycycline or other tetracycline antibiotics?