Are you aged between 18 and 60?

Are you pregnant or breast feeding, or intending either whilst on this medication?

Are you allergic (hypersensitive) to any of the following:

• A topical antifungal treatment (such as clotrimazole or miconazole)
• Antifungal tablet (such as fluconazole)
• Cetostearyl alcohol

Are you experiencing any of the following:

For women only:

• abnormal or irregular vaginal bleeding or a blood-stained discharge
• vulval or vaginal ulcers, blisters or sores
• lower abdominal pain or pain when urinating
• fever or chills
• nausea or vomiting
• diarrhoea
• foul smelling vaginal discharge

For men only:

• penile sores, ulcers or blisters
• abnormal penile discharge
• penis has started to smell
• pain on passing urine

You confirm that you:

• If intended user is male, their sexual partner has thrush
• Have not had more than two infections of thrush in the last 6 months
• Are not allergic (hypersensitive) to clotrimazole, other antifungals and thrush treatments or any other ingredient
• Do not have a history of a sexually transmitted disease or exposure to a partner with sexually transmitted disease

Do you agree with the below:

• The treatment is for your own use
• You will contact us and your GP should you experience any side effects from the treatment, if your condition changes or if your medical circumstances change.
• You will read the patient information leaflet supplied with your medication
• You have completed this questionnaire yourself and fully understand all the information
• Your responses are honest and accurate, and you understand that this is necessary for a safe medical assessment
• You agree to the terms & conditions, privacy policy, & data sharing policy