Period Delay - Consultation

What is your date of birth? (Treatment available for patients aged 18 and over.)

What is your gender?

Are you currently pregnant, trying to become pregnant, or unsure if you may be pregnant?

Yes

Are you currently breastfeeding?

Yes

When is your next period due?

Has your period already started?

Yes

Are your periods usually regular?

Yes

How many days would you like to delay your period for?

What is your reason for wanting to delay your period? (Optional)

Have you used period delay tablets before?

Yes

Have you ever been diagnosed with any of the following conditions? (

Has anyone in your immediate family (parent or sibling) had a blood clot before the age of 50?

Yes

If you have any other medical conditions not listed above, please provide details.

Are you currently taking any prescription, over-the-counter, herbal, or hormonal medications (including contraception)?

Yes

Please list all medications you are currently taking.

Do you have any allergies to medications?

Yes

Have you ever had an allergic reaction to norethisterone?

Yes

Do you smoke? (Including cigarettes, roll-ups, cigars, or vaping.)

Yes

Please provide your height.

Allowed values range from 100cm to 220cm

Switch to ft, in

Please provide your weight. (BMI calculated automatically for clinical assessment.)

Allowed values range from 40kg to 250kg

Switch to st, lb

Have you recently had major surgery or been immobile for a prolonged period?

Yes

Please confirm you understand that:

I confirm that I understand and agree to the above

To support safe prescribing please provide your GP details.

Yes

Would you like us to notify your GP about this treatment?

Yes

Do you consent to us contacting your GP if necessary for clinical safety?

Yes