About you

Please answer the following questions about yourself (or for the person that will take this medicine) If you get stuck or need any help, use our CHAT button below or give us a Call on 01639 502860

What is your age (or the person who will use this medication)?

If you are not the person who will use this medication, please enter their details here (only with their full consent)

Please describe in detail who the intended user is and answer all questions on their behalf

What is your biological gender?
Please select your option

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

Do you have any medical conditions or previous surgeries?

If yes please provide more details

Yes

Do you have cardiovascular (heart) conditions or have had a stroke?
If yes please provide more details

Yes

Do you have any liver or kidney problems?

If yes, please provide details

Yes

Do you have diabetes?
If Yes is this Type I or II

Yes

Is your immune system suppressed through disease, treatment or medication?
If yes please provide more details

Yes

Please provide more information about your living and work conditions
e.g. I live with 2 people and a cat, am a painter and decorator

Do you take any medicines?
Please list all your current prescription medication, medicines you buy including any herbal medicines and recreational drugs if taken.

Do you drink alcohol?
If Yes please provide more details on how many units per week and usually when consumed

Yes

Are you a smoker or an ex-smoker?
If yes please provide more details

Yes

What is your Body Max Index?
If you're not sure provide and estimate as we can check this before a prescribing decision is made

Please select either Metric or Imperial measurements :

Metric (Centimetre and Kilograms)
Imperial (Feet and Pounds)

Height

feet inches

Weight

stone lbs

Check BMI

BMI Calculation :

Do you currently feel severely unwell?
If yes please provide more details

Yes

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

Yes

About your Health

Please answer the following questions to help us ensure this medicine is safe for you to take

Why do you want to delay your period?

Have you used any period delay medication in the last month?

Yes

Are you currently using any contraception?
If yes, please provide details

Yes

Are your periods normally regular and predictable?

Yes

Do you ever have unexpected or unusual vaginal bleeding?

Yes

Do you have endometrial hyperplasia (thickening of uterus lining)?

Yes

Have you been immobile for a prolonged time (bed rest) or are you due to receive surgery?

If yes, please provide details

Yes

Do you or your family have any history of thromboembolic disease (blood clots)

Yes

Are you being treated with steroid hormones?

Yes

Have you been told by a doctor that you have high cholesterol?
If not, please explain how you discovered you have high cholesterol.

Yes

Has your doctor told you that you suffer from migraines?
Please provide details in this box here...

Yes

Do you have any eye problems? This includes:
Papilloedema and Retinal vascular lesions

Yes

Have you previously had a transient ischaemic attack (mini stroke) or stroke?

Yes

Have you had your blood pressure measured in the last 12 months?

Yes

Do you have inflammation of your veins (superficial phlebitis) or varicose veins?

Yes

Have you been diagnosed with asthma?

Yes

Do you have any autoimmune condition such as systemic lupus erythematosus?

Yes

Do you have a known or suspected cancer, or have you had cancer in the past (e.g. breast cancer)?
If yes, please provide details

Yes

Do you have a current or previous history of depression, suicidal thoughts, generalized anxiety disorder or any other psychiatric disorder?

Yes

Do you suffer from severe pruritus (itchy skin all over the body)?

Yes

Do you have porphyria or jaundice?

Yes

Do you have epilepsy?

Yes

Have you previously had severe pruritus or pemphigoid gestationis (an itchy rash) during pregnancy?

Yes

Have you previously suffered from jaundice, chloasma or preeclamptic toxaemia (high blood pressure) during pregnancy?

Yes

Do you (or close family) have a history of recurrent miscarriage?

Yes

Have you been told by your doctor you have an intolerance to any sugars (e.g galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)?
If yes, please provide details

Please provide details in this box here...

Yes

Are you willing to take measures to avoid pregnancy (e.g. by using barrier contraception) during treatment.

Yes

Are you allergic to norethisterone or any other similar hormone medicines?

If yes, please provide details

Yes

Our Prescribing Contract

Do you agree to the following?

You will read the patient information leaflet supplied with your medication. The treatment is solely for your use (or the person you have completed this for and with their consent). 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.

Yes

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

Do you agree to tell your doctor or pharmacist about any side effects you may be experiencing with the medicines and any progression of symptoms?

Yes

Do you agree you will contact us and inform your GP if you start new medication or if your medical conditions change during treatment?

Yes

Is there anything else we need to know that is relevant to this consultation?

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Period Delay

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Period Delay

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