Period Delay Risk Assessment Form

Period Delay Patient Risk Assessment and Consent Form

Please read this section carefully before completing the consent form

Norethisterone 5mg tablets are used for adult females of 18 to 50 years to postpone menstruation (period delay This treatment is intended for non-regular use and only onesupply is allowed every 6 months. You should contact your GP if you required a more frequent treatment regimen.

Name*

First NameLast Name

Address*

Tel*

Email*

example@example.com

GP Name

GP Address

Communication between doctors involved in your treatment helps provide the safest and most effective healthcare. Do you want your GP to be notified for this*

YesNo

Medicines and their possible side effects can affect individual people in different ways. The followingare

some of the side effects that are known to be associated with Norethisterone.

Just because a side effect is stated here does not mean that all people using this medicine willexperience that or any side effect.

Patient / Applicants may experience a rise in blood pressure, jaundice (yellowing of the skin or whitesof the eyes), migraine-type headaches, signs of sever hypersensitivity (anaphylaxis): e.g. swelling of the mouth, tongue, face, throat, difficulty breathing, wheezing, severe skin rash, itch, redness, if you become pregnant unusually bad headache, sever itching (pruritus), other liver problems and signs .g.abdominal pain, nausea, vomiting, tiredness, dark brown urine, any sudden changes in eyesight, hearing or speech, any changes in sense of smell or touch. If you are concerned with the side effects, you may talk to the pharmacist who oversees this treatment or your GP for further information before proceeding with treatment.

Drowsiness is rare with this medication, but may occur and interfere with performance ofskilled tasks e.g. driving Excess alcohol should be avoided when taking Norethisterone.

Applicant (or parent/guardian in the case of children/adolescents) must answer thefollowing questions comprising the applicant Risk Assessment Consent form.

General Questions*

	Yes	No
Please confirm you are between 18 and 50 years old.
Please confirm you would like to postpone menstruation (period delay) for non-regular use and that you understand that only one supply is allowed every 6 months and that you should contact your GP if you required a more frequent treatment regimen.

What is your height (in meters)?*

What is your body weight (in kilogram)?*

Type a question*

	Yes	No
Are you aware of any hypersensitivity (allergy), or any undesirable side effects to Norethisterone or any of its ingredients?
Are you pregnant or breast feeding or actively trying for a baby?
Do you have severe liver impairment?
Do you have severe kidney disease, or end stage renal disease requiring dialysis?
Are you taking any other medication either prescribed or over the counter?
Do you have any other questions you would like to ask your pharmacist about this product?
Are you currently using regular contraception?
Are you currently using mini pill/implant/injection?
Are you allergic to any medicines or other substances (e.g. peanuts/soya)?
Are you planning to take Norethisterone and fly at the same time?

Signature*

Date

I confirm and agree that any treatment prescribed for me is for my personal use only.