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
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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
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option
Do you have any medical conditions or previous surgeries?
If yes please provide more details
Do you have cardiovascular (heart) conditions or have had a stroke?
If yes please provide more details
Do you have any liver or kidney problems?
If yes, please provide details
Do you have diabetes?
If Yes is this Type I or II
Is your immune system suppressed through disease, treatment or medication?
If yes please provide more details
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
Are you a smoker or an ex-smoker?
If yes please provide more details
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
Do you currently feel severely unwell?
If yes please provide more details
Do you have any allergies?
If yes, please provide details
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About your Health
Please answer the following questions to help us ensure this medicine is safe for you to take
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Why do you want to delay your period?
Have you used any period delay medication in the last month?
Are you currently using any contraception?
If yes, please provide details
Are your periods normally regular and predictable?
Do you ever have unexpected or unusual vaginal bleeding?
Do you have endometrial hyperplasia (thickening of uterus lining)?
Have you been immobile for a prolonged time (bed rest) or are you due to receive surgery?
If yes, please provide details
Do you or your family have any history of thromboembolic disease (blood clots)
Are you being treated with steroid hormones?
Have you been told by a doctor that you have high cholesterol?
If not, please explain how you discovered you have high cholesterol.
Has your doctor told you that you suffer from migraines?
Please provide details in this box here...
Do you have any eye problems? This includes:
Papilloedema and Retinal vascular lesions
Have you previously had a transient ischaemic attack (mini stroke) or stroke?
Have you had your blood pressure measured in the last 12 months?
Do you have inflammation of your veins (superficial phlebitis) or varicose veins?
Have you been diagnosed with asthma?
Do you have any autoimmune condition such as systemic lupus erythematosus?
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
Do you have a current or previous history of depression, suicidal thoughts, generalized anxiety disorder or any other psychiatric disorder?
Do you suffer from severe pruritus (itchy skin all over the body)?
Do you have porphyria or jaundice?
Have you previously had severe pruritus or pemphigoid gestationis (an itchy rash) during pregnancy?
Have you previously suffered from jaundice, chloasma or preeclamptic toxaemia (high blood pressure) during pregnancy?
Do you (or close family) have a history of recurrent miscarriage?
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
Are you willing to take measures to avoid pregnancy (e.g. by using barrier contraception) during treatment.
Are you allergic to norethisterone or any other similar hormone medicines?
If yes, please provide details
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Our Prescribing Contract
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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.
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.
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?
Do you agree you will contact us and inform your GP if you start new medication or if your medical conditions change during treatment?
Is there anything else we need to know that is relevant to this consultation?
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