• Period Delay Risk Assessment Form

  • About You

  • Date of Birth*
     - -
  • Gender*
  • What is your ethnicity?*
  • Please confirm you are 18 to 50 years old?*
  • Please confirm you would like to postpone menstruation (period delay) for non-regular use and that you understood that only one supply is allowed every 6 months and that you should contact your GP if you required a more frequent treatment regimen.*

  • About your health

  • Do you have any hypersensitivity (allergy), or any undesirable side effects to Norethisterone or any of its ingredients?*
  • Are you allergic to any medicines or other substances (e.g peanuts/soya)?*
  • 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 currently using regular contraception or implant or injection?*

  • If you are taking regular pill/patch, a better way of delaying your period is taking your combined pill pack or your contraceptive patches back to back without a seven day break. We do not advise taking Norethisterone and your combined pill together. If you are using the mini pill, a contraceptive implant or a contraceptive injection and norethisterone together, it can result in a higher risk of having side effects from the hormones such as blood clots. We do not advise taking Norethisterone and your current treatment together.

     

  • Do you currently suffer from any of the following (may you please tick any that may apply)*
  • Are you taking any medication either prescribed or over the counter?*
  • Have you had another supply of Norethisterone tablet (in any strength or formulation)within the pas 6 months from this clinic or another healthcare provider?*

  • Acknowledgement

  • I understand norethisterone may worsen migraine, epilepsy and asthma*
  • I understand I should stop Norethisterone if unexpected side effects occur*
  • I understand that this treatment is intended for non-regular use and only one supply is allowed every 6 months. You should contact your GP if you required a more frequent treatment regimen.*
  • 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 consultation?*
  • Should be Empty: