Period Delay Assessment | Pharma Aesthetics

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Period Delay Treatment Medical Questionnaire

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Step 1 of 8

12%

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Period Delay Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Are you aware you need to be able to predict when your periods are due?*

Yes

No

Patient Note: Treatment should start 3 days before period is due.

Please confirm you are aware that the treatment should start 3 days before the period is due.
Please confirm once you understand by selecting yes above.

Are you female aged between 18-54?*

Yes

No

Patient Note: This medication is suitable for women who ware 18-54 and not taking any hormonal contraceptives.

Please provide more information below.*

Your Symptoms

Are you seeking to delay your period for a specific event or occasion?*

Yes

No

Please provide more information below.*

Have you used period delay medication before without experiencing any adverse effects?*

Yes

No

Please provide more information below.*

Is your menstrual cycle generally regular?*

Yes

No

Please provide more information below.*

Are you currently experiencing any premenstrual symptoms?*

Yes

No

Please provide more information below.*

Do you have a history of heavy or painful periods?*

Yes

No

Please provide more information below.*

Health

Are you currently taking any form of contraceptive pill?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any known allergies to norethisterone or any other progestogen-based medication?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you pregnant, or is there any possibility that you could be pregnant?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any history of thrombosis (blood clots) or are considered at high risk for thrombotic conditions?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you suffering from any liver disorders or have a history of liver disease?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions are designed to ensure that the prescription for period delay is suitable and safe for the patient, taking into account their current health status and medical history.

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Comments

This field is for validation purposes and should be left unchanged.

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16 Broadway, Rainham, Essex, RM13 9YW
01708 608860
info@pharma-aesthetics.co.uk

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