To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

0%

Born male
Born female


I haven't used Gina before
I have used 1 - 2 packs before
I have taken 3 or more packs



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This may be to any medicines or other substances e.g. peanuts/soya)


e.g. cancer, a thickening of the lining of the uterus/endometrial hyperplasia, endometriosis, liver disorders or jaundice, a blood clot


Either prescribed or over the counter, including herbal remedies, supplements, or recreational drugs.


Yes
No
Not Applicable

Yes
No
Not sure

  • dryness
  • soreness
  • itching
  • burning
  • painful intercourse

Vaginal symptoms

  • undiagnosed bleeding
  • smelly, or unusual vaginal discharge
  • severe vaginal itching (for example, that interferes with sleep)

Any changes to the look or feel of your vulva

  • sore red patches
  • thickening, a lump or scarring
  • itchy, white, smooth/crinkled patches of skin easily damaged
  • rash

Other symptoms

  • pelvic pain or pain on urination
  • lower abdominal pain, bloating or swelling



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  • This treatment is solely for your own use
  • You will read the manufacturer’s patient information leaflet and stop and report and adverse effects immediately to the relevant healthcare professional
  • Y0u confirm that you have answered all the above questions accurately and truthfully. You understand our team take your answers in good faith and base their decisions accordingly, and that incorrect information can be hazardous to your health.


  • If you develop any of the conditions listed under the ‘Do not use’ section in the Patient Information Leaflet and on the pack
  • If you have any new vaginal bleeding, spotting or itching