Period Delay Questionnaire

Select 'Yes' if you give permission to share this information with or seek more information from your GP, we will hold your order until GP approval has been given. Not providing consent may limit the services provided by the prescriber.

Yes

Please confirm that you have seen your GP, practice nurse or specialist consultant to discuss taking this medication and they are happy for you to take

Yes

Are you pregnant, breast feeding, intending to become pregnant or given birth within the last 6 weeks?

Yes

Have you been prescribed this before?

Yes

Was your last period late?

Yes

Do you have any family history of blood clots (including heart attacks) or breast cancer.

Yes

Are you currently experiencing any undiagnosed breathlessness or pains in your chest or pain/swelling in your calf?

Yes

Do you smoke?

Yes

Is your BMI >30kg/m² ( your Body mass index is your weight ( in kilograms) divided my your height in meters and then divide the answer by your height again)

Please enter a minimum of 1 word

Number of words entered: 0

Are you fully mobile?

Yes

Do you understand this medication is not a contraceptive?

Yes

Why do you need to delay your period

Please enter a minimum of 1 word

Number of words entered: 0

Please list any allergies or medical conditions you have.

Please enter a minimum of 1 word

Number of words entered: 0

Please list any medication you are taking, including over the counter or herbal remedies.

Please enter a minimum of 1 word

Number of words entered: 0

Have you been diagnosed with any of the following? • Heart or BP problems • Stroke • Thrombosis (blood clots) • Migraines • Breast or gynaecological cancer • Liver or Gallbladder problems • Undiagnosed vaginal bleeding

Yes

• I will read the patient information leaflet supplied with my medication • I will contact my GP or MyMedsUK if I experience any side effects • The treatment is for my use only • I have answered the assessment questions truthfully and accurately • I agree to the Terms and Conditions and I confirm that I am over 18 years old • I am aware that I may be contacted to give further information via phone or email and if I am not contactable this will lead to a delay in receipt of my prescription

Yes

Why are you looking to use our service instead of your own GP or other healthcare provider?

Please enter a minimum of 5 words

Number of words entered: 0

Please provide details of the last time you discussed this medical problem with your GP/Consultant. (Please include details such as date seen, their thoughts about your ongoing use of this medication and the next proposed review date.)

Please enter a minimum of 5 words

Number of words entered: 0

Based on the answers you have provided, we advise you to visit your GP for a personal consultation. Please make an appointment with your GP at your earliest convenience.
Alternatively, please revisit the questionnaire, if you think you made an error in your answers.

Great, you've be provisionally approved for this treatment. Click 'Continue' to complete your order.

We're nearly done.

Your Chosen Treatment:

Period Delay

Step 1: Questionnaire

Is your BMI >30kg/m² ( your Body mass index is your weight ( in kilograms) divided my your height in meters and then divide the answer by your height again)

Why do you need to delay your period

Please list any allergies or medical conditions you have.

Please list any medication you are taking, including over the counter or herbal remedies.

Why are you looking to use our service instead of your own GP or other healthcare provider?

Please provide details of the last time you discussed this medical problem with your GP/Consultant. (Please include details such as date seen, their thoughts about your ongoing use of this medication and the next proposed review date.)

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